Jacob Z. Hess, Ph.D.
“I have had beatings to the point of unconsciousness – with arms broken and taken out of the socket and that compares nothing…doesn’t even begin to be the pain that became every day, just right here [pointing to her chest] – this thing that wouldn’t come off – that made it hard to breathe…like, I would rather have people beating the crap out of me than to have been where I was just inside. It hurt that bad…there were times I thought it would kill me – all on its own.”
That’s how one woman described to me her experience of serious depression – comparing her more recent emotional anguish to horrendous earlier abuse as a child.
Given the intensity of that kind of pain, it’s only understandable that we end up seeking for anything that might possibly relieve it. Like many people, I’ve witnessed my own loved ones grappling for years with how to decrease and manage this kind of mental/emotional distress…desperate for ways of finding more lasting healing.
After so many years of seeking-but-not-finding, it’s also understandable why many people begin to give up on the possibility of lasting healing – accepting instead, a need for ongoing, even life-long, treatment and management.
It perhaps shouldn’t surprise us, that increasing numbers of people rely on psychiatric medications over longer periods of time. A 2017 U.S. Centers for Disease Control and Prevention study found that many Americans are taking antidepressants over an extended period of time. Laura Pratt of the CDC’s National Center for Health Statistics (NCHS) said, “Long-term antidepressant use was common,” noting that “one-fourth of all people [surveyed] who took antidepressants over the past month reported having taken them for 10 years or more.”
I’m writing to review the surprisingly substantial evidence that long-term psychiatric treatment, in particular, is inadvertently making the individual burden of mental health problems worse over time. To be clear, this does not deny the real relief that many can and do experience with medical support, especially initially. Questions raised here focus on the long-term trajectory of treatment, examining the extended outcomes rarely taken into account in our prevailing public conversation about mental health.
Alongside many other narrative accounts gathered over the years in my own research, I will illustrate with content from a mental health educational initiative within my own faith community, including 22 interview stories on a new LDS-specific mental health website and one video posted October 2016 on the Mormon channel that has now been viewed over 420,000 times (which video, of course, is simply one instantiation of a popular perspective in American culture today, and is will considered in that light).
This is not a quick 5-minute read (although if you’re in a hurry, clicking through the 9 embedded videos below will give you some of the main points). Given the seriousness and sensitivity of these issues, I will be thorough in providing supportive references and illustration for what follows. Prior to taking up more of the conventional research exploring clinical outcomes, we will begin focusing on common patterns of socialization leading patients and families to arrive at a point where they adopt and embrace this approach (and its associated narrative or way of thinking).
The next question then becomes: How does that narrative (and associated treatment recommendations) compare with the best available scientific evidence on the brain and the outcomes of long-term psychiatric treatment?
Here, I turn the several lines of evidence – both historical and scientific – that raise serious questions about the longer-term approach that is increasingly common. While short-term evidence of effectiveness exists (which is why the FDA has approved the medications), the picture arising from long-term psychiatric studies strongly contraindicates our current patterns of long-term use. This conclusion was first brought to the fore by award-winning reporter Robert Whitaker in his books over the last decade. As a way to illustrate these points clearly, I share for the first time, video excerpts from my own interview with him, where I ask about his work to review all studies of long-term outcomes for psychiatric medication in existence.
I also provide the same twenty different studies of long-term antidepressant use that Whitaker reviewed, so readers can see for themselves that concerns raised here are consistently supported by the best available science on long-term outcomes. This body of research has continued to receive astonishingly little attention in either the public or professional mental health conversation.
After a review of the evidence, I return to the context of my own beloved (LDS) faith community as a case study of how much this particular narrative and approach has been adopted by institutions across the United States. While acknowledging the chorus of powerful spiritual witnesses, I highlight how the approach reflected in the LDS mental health initiative now closely mirrors the essential narrative being adopted widely across American society today. 
After summarizing some of the conflicting messages about hope, healing, and agency, I conclude with a discussion of the personal consequences of “learned hopelessness.” I also highlight the immensely hopeful message that could reaffirm possibilities for lasting healing from mental illness, but which has also largely been ignored in broader public and professional conversation.
While acknowledging the shock this may be to families and professionals unaware of this research, I underscore in the final section the real possibilities of simple treatment protocol adjustments that may make a difference, along with the value of every voice in this conversation – trusting that, generally speaking, everyone offering support to those facing mental/emotional distress is simply doing the best they can do.
Note: Although raising difficult questions, this paper does not represent any kind of attack on the LDS Church or its leaders, whom I love and trust. The focus of my critique is a popular narrative that has been adopted by our faith community and increasingly played out in our mental health education efforts.
Secondly, as one might expect, suggestions that follow in this paper cannot and do not substitute for specific professional advice on medical matters, for which a professional license is required. What follows are public health recommendations of a researcher based on various sets of evidence being overlooked. Where I raise concerns about prevailing medical practice, I do so as one participant in a broader public conversation that needs to happen. I respect that others will disagree with this. If this raises questions about details of your own treatment, I recommend you take those questions up with your treatment provider.
Narrative Socialization: How We Come to Embrace One Mental Health Story
In December, I published a review of narrative evidence illustrating ways in which dominant interpretations of certain LGBT activist groups can play out over time in a way that (I argued) inevitably, directly and predictably leads people to certain outcomes.
I believe the same thing can be said of certain, dominant mental health narratives in America today. Indeed, the whole reason I took that approach to analyzing sexuality narratives was because I had done the same ten years prior with depression.
Personal interest. As mentioned, like most people, I have dear ones who have faced depression and other serious mental/emotional challenges for years. For a time, they seem to get a handle on it and do well…then back into the abyss. Does anything exist that could lead someone to long-term, lasting healing from depression?
Motivated by these questions and experiences, between 2004 and 2007, I completed an in-depth research study on the lived experience of depression and its treatment. I did so after hearing wildly conflicting accounts of people’s experiences on antidepressants – from dramatic stories of rescue (“Prozac saved my life”) to equally dramatic stories of devastation (“my son killed himself after starting Prozac.”)
I wanted to learn more.
So, I spent several years sitting with people facing depression, documenting and analyzing in-depth their decades-long narratives. I also read the scientific literature to try and make sense of the vast discrepancies in conclusions: Why do some people appear to be having literally redemptive experiences with a medical approach to depression, while others come to see it as having harmed them?
As one might expect, the answer to that question turned out to be complex, involving an interplay of diverse interpretations overlaid on top of equally diverse (and evolving) experiences with medication. In what follows, I highlight ways in very abbreviated fashion a handful of themes that illustrate how individuals come to make sense of and end up “narrating” acute suffering over time – adopting and “downloading” a particular narrative as part of this.
Urgency & panic. Out of the excruciating pain common to depression arises a desperation that many people come to feel about anything that might relieve their suffering. One man told me, “Things had gotten so bad for me that I said, ‘I’ll do anything…I will do anything if you tell me that it will make me feel better.’ If you told me the problem lived in my finger and I had to cut it off, I would really, I would have done anything to make that go away.”
Loved ones often compound and multiply the sense of urgency, with another person recollecting his own desperation as a young man, “At that point my mom decided, she’s like, ‘We have got to do something about this. We’ve got to.’”
The extent of pain (and panic about the pain) can become heightened enough that many people become willing to do things they may not otherwise do.
A common wrestle. For different reasons, one thing that many people feel personally resistant to is psychiatric medication as a primary way to address the pain (especially if that is presented as a long-term necessity). Research on hundreds of patients asked to take medications on a long-term basis for asthma, heart issues, cancer or kidney problems, found approximately 1 in 3 people (36%) experiencing strong concerns about the potential adverse effects with chronic use, including the dangers of dependence and other long-term effects.
Compared to shorter-term use of a medication, then, it is the longer-term usage that prompts more serious concerns for many people. This is especially the case with antidepressants and other psychotropic medications, where the level of public distrust is often greater. In one public survey, psychiatric medications were believed to involve significantly more severe side effects and prompted more fear of losing control.
This kind of internal resistance is portrayed almost exclusively in the medical literature as patient naïveté to the incontrovertible benefits of pharmaceuticals. Consistently, most professional writing on the topic center around tactics to overcome patient concerns and persuade them of the benefits of compliance. For instance, one 1986 piece promoted “The effects of a psychiatric patient education to medication program on post-discharge compliance” while another the same year spoke disappointingly of the “failure to enhance compliance” following an effort to educate patients more directly about the value of the psychotropic medications they were being offered.
Predictably, then, transformations of belief are a common patient experience in their interactions with medical professionals. This is especially true with the high level of trust medical authorities are given in the American public generally (and especially true when facing distress or alarm about unusually high amounts of pain).
Galvanizing moments. And that’s precisely what intrigued me about this particular Mormon Channel video, which represents in an almost ideal form the kind of “galvanizing moment” identified in my dissertation study, wherein one “illness narrative,” as pioneering researcher Arthur Kleinman called it, is transformed into another.
In this case, a woman named Heather shares the aching weight and pain of depression, before acknowledging the same kind of common resistance described above: “I never wanted to be medicated…ever. I didn’t want to be put on medicine for this.”
When Heather describes her doctor reviewing “all sorts of medications we can try,” she thus responds, “’I don’t want that.” She tells the physician, “I didn’t want to be on anything.”
There is an argument that this impulse and intuition from individuals ought to be trusted and incorporated into a plan for intervention, especially given the many possible ways to support someone with depression.
However, instead, we see the kind of patient persuasion encouraged in the prevailing narrative. When the doctor asks Heather more about her resistance, she says, “I feel like the Savior should be able to take this away from me – I feel like my prayers should be answered. I don’t want this – and He should be able to take this away.”
At that point, the doctor looked Heather straight in the eye – getting closer to her and saying, “Who ever said I’m not the answer to your prayer?”
That moment becomes profoundly influential – a moment when Heather’s story profoundly shifts – punctuated by her belief that God penetrated her heart and confirmed that, “Yes, she’s right.”
As reflected here (and in many other similar accounts I’ve reviewed), this kind of a galvanizing moment can usher in an entirely new story: about depression, about the brain, about healing – and often, about identity itself.
A redemptive story. The remainder of Heather’s story unfolds like a literal and miraculous redemption from her suffering: “And today, I’ve never felt more like myself – finding joy in my life, I still have emotions…I don’t feel numb inside…I’m me. And I’ve found joy in my life.”
Although Heather acknowledges ongoing difficulties (“I still have days where it’s hard and I’m sad”) and while the title of the video argues against overstating the shift she experienced (“Living with Depression”), the overall story arc paints an especially vivid picture of deliverance.
Dan McAdams, a narrative researcher at Northwestern University, calls this kind of story reviewed above a “redemptive sequence,” defined as “an affectively negative or bad life-narrative scene…followed by an affectively positive or good outcome, with the good ultimately redeem[ing] or salvag[ing] the bad that precedes it.”
And, indeed, especially in the early phases of an antidepressant or other psychiatric medication, that’s precisely what some end up reporting. One woman told me, “the magic part of my life was taking that Prozac. It just seemed to do everything. I had the energy, I was losing weight, I could stay up (laughs) until 3 a.m. cleaning and everything was organized, and it was just wonderful. It was like the superwoman I wanted to be…it was just the magic pill.”
Another woman remarked, “It was an absolute miracle because…I was calm enough to handle the situation and to cope with everything and then I was able to get some sleep, and I hadn’t gotten sleep for years.”
This kind of vivid language – “absolute miracle,” “magic pill,” “superwoman,” feeling like “a million bucks,” life had “never been better” – is very common to these kinds of accounts. Other accounts on the LDS mental health site reflect similarly vivid transformations:
- “Once the medication worked, once I got on the right medication, it just all went away, like the curtains opened back up. The darkness was gone.” (Alan’s Story)
- My Grandpa talked once about the first time he put glasses on; prior to that, he thought the world was just supposed to be foggy. And when he put the glasses on, the world looked way better…I just thought the difficult emotions were normal. And when I started getting some help, the medication was kind of like putting glasses on my brain.” (Ryan’s Story)
Obviously not everyone has an immediately positive effect on a psychiatric medication, with, for instance, approximately one third of people starting an antidepressant typically reporting no response and another third reporting some kind of deterioration on a first prescription. But whether it happens on a first, second or third attempt, those who go on to experience some kind of a lift or relief from medical treatment, appear to come away with a larger conviction and trust in this new redemptive narrative that is quite strong.
And no surprise, right? For someone who has experienced that level of darkness and despair, it’s not hard to understand why he or she would try any source of relief and why they’d be elated to actually find some.
The real surprise, for me at least, is in what happens next.
It’s not working anymore. As is true of many medications, at some point the biological effect subsides as the brain/body habituates to the drug. Other physiological changes in the brain or body also typically take place over the course of treatment. In the case of antidepressants, for instance, there is evidence that the influx of serotonin leads natural serotonin receptors to “downregulate” – effectively shutting down in order to maintain homeostasis (and not overdose on serotonin).
As a result of these kinds of changes, most patients eventually arrive at the day when the initial effect of the medication ceases. As many know from personal experience, this kind of a shift can be deeply discouraging on a personal level. Speaking of a participant in his own study, Boston College sociologist David Karp writes of the “unfathomable disappointment [individuals] feel when a medication that temporarily ‘cured’ them simply stops working,” comparing it to the “shock experienced when a lover suddenly leaves.”
What typically happens in this moment is an increase in dosage in hopes of regaining the initial effect.
Sometimes this works. Other times it doesn’t. In the meanwhile, individuals are often asked to simply wait and watch, while a trial and error process unfolds. As many families know, this process can be excruciating.
This is all endured, however, in earnest hopes of finding another medication that works for an individual (in some kind of a more permanent way).
An enduring conviction. Even as especially acute side-effects sometimes compound over time, people’s attention can remain profoundly riveted on the ongoing redemptive potential of medical treatment.
And that’s really where the surprise comes for me: Even when the medication has essentially ceased working and/or the side-effect profile outweighs any benefit received, the expectation can remain fixed on what new medical relief will be provided next. One woman who had told me about an initially powerful moment on Prozac where she “felt herself” went on to describe how that initial effect dissipated within a few months. Even so, it was dramatic enough that she kept searching for a dosage level or medication that would duplicate the almost magical, initial transformation.
Speaking now 15 years after that moment, she expressed a mixture of lament and yearning at not being able to find that relief again. In that and other stories, one thing that has stood out is how committed most people remain to the idea that they will eventually find a better treatment that resolves or relieves their pain for good. Even when someone goes on to experience excruciating levels of additional suffering in the years of treatment, the original trust in this approach often remains strikingly consistent.
This is true even in cases of dramatic new side-effects.
Curious interpretive patterns. One woman told me the story of having panic attacks and high levels of anxiety shortly after starting a new antidepressant. When I asked her, “Was that something you had experienced before?” she responded, “I had anxiety but I had never really experienced a panic attack, I think, until I went on the Zoloft.”
She continued, “I remember calling [my friend] saying, ‘this is making me have panic attacks!’ …and she says ‘Sarah it’s not the medication, it’s your anxiety that you want this to work so bad’ and I kept saying ‘are you sure? Are you sure, Emily!?’”
I’ve spoken to multiple individuals who tell me similar stories, including a man the other day who recounted his physician insisting “No, your medication cannot be hurting you” when he reported how his anxiety had skyrocketed after starting psychiatric treatment.
I find this discrepancy especially fascinating: When positive feelings are experienced by patients, they are much more likely for these to be attributed to an antidepressant. But when negative feelings are experienced, they are much more likely to be attributed to the underlying conditions themselves.
Why? Why not look at other explanations for the positivity (or negativity)?
Perhaps because we’re simply staying consistent with the larger story we’re used to telling and believing about mental illness.
Like a car engine without oil. As a young teenager facing emotional distress, one personal friend was told that his depressed brain was “like a car engine without oil.” Speaking of her child, a parent told me, “Her brain is wired in a way that her mental illness will be a monkey on her back the rest of her life.”
It’s true that for some people, hearing that a deficiency in their brain is responsible for their pain feels relieving – in the sense that, “now I know there’s a physical explanation.”
For others, however, that new belief in a fundamentally deficient brain can lead to a place of new despair.
One reason a new despair can emerge for some is what this appears to mean for their future.
For the rest of your life. Alongside this new view of their brain comes a new view of recovery.
During one interview, a woman asked me: “Is there a getting better from this or not? I mean, they told me in the beginning there wasn’t…but I’m hoping that I can make improvements that are permanent…”
I asked her, “Who told you that you don’t get better?”
She responded, “Well my initial diagnosis – they said this is something permanent. This isn’t something that you’ll ever not have.”
I’ve heard the same kind of story many, many times:
- When asked, “Do you ever talk about ‘getting fully better’ from depression?” one younger person said: “I don’t think that’s possible. I just…I want to, but I don’t think that I…I think, just a couple years ago I just faced it that I’m just always going to have to have something.”
- A father said this about his child, “I don’t think there’s going to be a time that she’s going to be well. We’re going to have to stay on it, stay on it, stay on it forever.”
- Another person was told by their doctor about depression, “This will be something you face the rest of your life.”
- And a mother was told by a medical professional, “This will be something your son struggles with the rest of his life.”
- Another mother said this about her daughter facing serious mental illness, “there is no cure—that she needs to learn to live with it the best she can. I’m expecting her to regress.”
Across all these retrospective interviews, I have seen evidence for how this belief in lasting disability can be profoundly deflating for some people – leaving them dispirited and feeling somewhat helpless.
IF it’s true that the mentally ill brain is fundamentally deficient and IF it’s true people will likely face these conditions the rest of their lives, then it follows logically that they will likely need some sort of permanent, external support.
Forever treatment. The permanency of treatment has become such a common feature of people’s experiences, that I’m shocked when people hear or come to believe anything else. More commonly, this is what I hear:
- One woman told me that during a time when she was feeling depressed, her doctor prescribed her an antidepressant and told her, “you’ll likely need to be on this the rest of your life.”
- One individual was told by a psychiatrist in the mission field: “you will need to be on these meds the rest of your life.”
- One man who had been on an anti-anxiety medication for years told me, “My doctor didn’t say anything about duration. I just assumed it would be permanent.”
As reflected above, we see the arrival of a common perspective that many people facing serious mental/emotional challenges have now embraced: permanent brain deficiency, enduring (even life-long) affliction and long-term medication use. How to help people accept this story (and its associated course of treatment) constitutes a great deal of our mental health conversation today (go here to review my latest academic paper reviewing the public mental health conversation in America today).
And let’s be fair: IF this story about mental illness is true, then there’s no question we should be telling people about it…even if it’s a hard reality to accept.
But is it true? How does this story compare with the best available scientific and historical evidence focused on the long-term course of depression and its treatment?
Acknowledging the Larger Clinical & Historical Evidence Base
What many people simply don’t realize is that some of the best available scientific evidence raises serious questions about long-term treatment protocols. As detailed below, the mental health narrative reviewed above conflicts sharply with consistent empirical evidence, a conflict we’re hardly talking about in the broader mental health discussion in America.
The central message of this paper is that this conversation is dearly needed – with space for all voices, and trust, once again, that everyone is good-intentioned.
In what follows, three different bodies of evidence are reviewed. Together, they underscore the reality of a significant science-practice conflict that needs to be confronted – and adjustments that need to be considered to our standard protocols.
1. Scientific Good News: Neuroplasticity & Epigenetics.
Virtually all neuroscientists are now focused on what is called “brain plasticity” – exploring the surprising malleability of the brain. As Gary Marcus, scholar at New York University, states: “The brain is capable of…impressive feats of experience-driven reorganization…The structure of the brain is exquisitely sensitive to experience. Nature has been very clever indeed, endowing us with machinery not only so fantastic that it can organize itself but also so supple that it can refine and retune itself every day of our lives.”
Studies have confirmed this neural network growth, for instance, when individuals learn a language, participate in cognitive-behavioral therapy and engage in meditation practice. There’s also exciting evidence for heartening life-long recovery rates even for severe mental illness.
As one psychiatric researcher at UCLA, Jeffrey M. Schwartz, has elaborated, “Contrary to the notion that the brain has fully matured by the age of eight or twelve…it turns out the brain is an ongoing construction site…The neurons that pack our brain at the moment of birth continue to weave themselves into circuits throughout our lives…as mutable as a map of congressional districts in the hands of gerrymanderers.” Steve Yantis, a professor of brain sciences at Johns Hopkins University further summarizes, “The bottom line is, the brain is wired to adapt…There’s no question that rewiring goes on all the time.”
Perhaps even more intriguing, it is not just the brain that is being found to be more dynamic than previously thought. In contrast to the long-held notion of genes-as-blueprint, researchers have also documented how genes frequently manifest differently depending on individual lifestyles and actions. This gene-environment responsivity is formally known as epigenetics—what Nobel laureate Barbara McClintock has called the “fluid genome.”
In recent years, these research advances in understanding changeable biological vulnerabilities have prompted substantive revisions to theories of various mental health conditions—including with clinical depression, general fear and anxiety, obsessive compulsive disorder, attention problems and delusional disorders and schizophrenia.
If all this is true, the real question is this: why aren’t those facing serious mental/emotional distress hearing about this? What could it mean for the millions of people to find out about this?
Our experience as a non-profit, after years of teaching neuroplasticity and other concepts in our online class Mindweather 101, is that even just this knowledge can boost hope considerably. For instance, upon learning about neural plasticity, one woman told me “wow – that means I can do something about this!”
If the only thing that changed in our mental health conversation was making sure everyone knows about brain changeability, it would make a big difference.
But we’re not doing this.
NAMI’s popular Family-to-Family Educational class has been provided to families for facing mental illness for decades. In the accompanying 495-page manual provided to participants, the brain is talked about a great deal – from imbalances to other theories of how the brain can come to malfunction. The terms “neuroplasticity” or “brain changeability,” however, do not show up a single time.
At the bottom of page 4:22, the overall concept is mentioned, in a conflicted, unusual way: “One of the hottest new areas in brain research…is neurogenesis, a still-controversial hypothesis claiming that brain cells can heal, or regenerate.”
When touched on once in the curriculum, that’s how the widespread, virtually universal consensus among brain scientists is portrayed in the NAMI class manual for families facing mental illness.
What else are we not teaching people (that could make a difference)? On that note, it is crucial to consider historical evidence that illustrates the natural course of outcomes for psychiatric conditions prior to the rise of a pharmaceutical approach to addressing them.
2. Evidence of Natural Recovery & Time-Bound Conditions.
For simplicity, I link below to details of the historical evidence for outcomes prior to the advent of antidepressants. As you will see, the historical record paints a surprisingly optimistic picture of the natural course of outcomes for depression. In many cases, people found these conditions to be time-limited in the period prior to the advent of chronic medication management. Similar patterns show up for other mental health conditions as well.
If it’s true that the natural course of outcomes for depression and other conditions is fairly optimistic, why aren’t patients hearing about this? What might it mean if they did? (And why and how have we forgotten this?)
3. Long-term Outcomes of Antidepressants and Other Psychiatric Medications
There is more good (and bad) news in another final body of evidence. Those who have looked across the existing long-term studies have found strikingly consistent patterns. Compared to the benefits identified in studies of shorter-term results, these same medications (antidepressants and other psychotropics) show more counter-intuitive effects long-term. In particular, long-term use of antidepressants – in study after study – leads to a worsening chronicity of depression and an increasing symptom burden. You can review this for yourself in the link below detailing twenty different published articles confirming this pattern. Each of these articles and some of their key, relevant findings are reviewed below.
These same patterns identified in the longer-term antidepressant studies show up in long-term studies of anti-anxiety and anti-psychotic medications (see summary video below: Long-term Research on Different Kinds of Psychiatric Meds).
Rather than an anomalous finding, it’s important to reiterate that a pattern of worsening chronicity has consistently shown up in every class of psychiatric medication studied long-term (as Robert Whitaker explains in this video below: The Consistency of Patterns in Long-term Psychiatric Outcome Research).
If these long-term outcomes are true, what should it mean for our protocols of treatment? There are some common-sense adjustments that could make a big difference, such as supporting people in the option of tapering off.
Why aren’t we talking about or considering this?
Perhaps one reason we haven’t done so adequately is the flood of shorter-term studies that typically draws more attention in both public and professional conversation about mental health.
Immediate treatment experience. For people who have positive initial experiences with psychiatric treatment, it can be hard to consider the possibility that this same treatment may have reverse effects later on.
Sometimes the experience of trying to step away from a medication can only confirm this conviction further. I’ve seen may instances of someone deciding to taper off a medication and starting to experience difficulties. This can understandably be scary and have a real effect, especially when the worsening symptoms are interpreted as a return of the condition and proof of the biological necessity of medication.
Far less attention goes to other ways to interpret the difficulties that happen during tapering – for instance, as the expected and predictable reflection of withdrawal effects. In the absence of this larger awareness, it starts to feel almost crazy to consider why someone would (ever) come off a medication that has once helped them. See video below: Overlooking Withdrawal Effects
The same kind of disbelief at the possibility of tapering is often evident in treatment professionals, who most often hold the first interpretation, hardly considering the second. Following a depression presentation where I had shared some of the reasons for optimism for lasting recovery from depression, I had a doctor approach me immediately after finishing, rebuffing me gruffly: “I haven’t seen people recover like you’re talking about – and I’ve worked with many hundreds of people facing depression.”
It was clear that for this physician, his own clinical experience was proof enough that the possibilities I was raising were not true. Unfortunately, he couldn’t see the irony of the fact that the evidence of his own practice confirmed the long-term studies I had just finished reviewing. In fairness, he just honestly couldn’t see it.
Robert Whitaker likewise tells the story of one doctor telling him, “I don’t want to hear this anymore…I know these drugs work. I see them work every day.” He reflects, “That was an honest response,” noting that this is what the immediate, day-to-day experience of his professional world kept suggesting to him.
And in fairness, how could you not reach this same conclusion if you kept seeing examples of short-term benefits (without equal attention to long-term effects). In further confirmation of this is the prominence of short-term outcome studies.
Short-term studies. Another doctor once told me that he knew the psychiatric treatments he offered were undoubtedly safe and effective “because of the randomized controlled trial data” – which was the “only thing he cared about.” No question: It’s hard not to ignore over a thousand short-term randomized trials that have been conducted with antidepressants over the last several decades. As Dr. Ioannidis at Tufts University notes, “Statistically significant benefits have been repeatedly demonstrated and the medical literature is flooded with several hundreds of trials embraced to be positive.”
I conducted a “randomized controlled trial” several years ago, focused on a mindfulness intervention for teenagers. I was baffled with the complexity of decisions we had to make, all of which had significant bearings on the results. Given the impressive efforts at control in these studies, however, they are often automatically taken to be the gold-standard evidence by which decisions need to be made. Far, far less attention has been given to some of the limitations of these studies – as well as the long-term evidence to complement their findings reviewed earlier.
In the absence of this broader evidence reviewed (and particularly if short-term trials are the only thing we’re paying attention to), it’s understandable that we will reach conclusions based on the short-term patterns. For that reason, Dr. Ioannidis goes on to suggest that “higher evidence standards, with very large long-term trials and careful prospective meta-analyses of individual-level data may reach closer to the truth and clinically useful evidence.” Dr. Bonnie Kaplan, from the University of Calgary, has likewise warned against an over-reliance on RCT’s, and called for a similar broadening of the criteria by which we make evaluation decisions on medications and other health products.
Similarly, Jeff Lacasse and I argued back in 2011, “More long-term, in-depth, and balanced studies might provide for clients and the general public a more accurate and honest assessment of what effects can legitimately be expected from a particular treatment.” We went on to suggest, “Within the open dialogue between results from multiple research approaches, a collective consensus can emerge that is much stronger than a meta-analysis of 30 studies employing the same methodology.”
The danger of this kind of single-minded reliance is heightened by the fact that RCT’s are so excessively expensive, industry is often the only ones able to fund them. Does that matter? Systematic reviews indeed show that industry-funded studies are more likely to reach outcome conclusions favoring the sponsor’s product, when compared with research independent of corporate interests.
Thus, we see the importance of critical thinking about the data presented as establishing efficacy and safety. These same studies often form the basis for “best practice” standards physicians feel obligated to follow.
In addition to these two sets of evidence (short-term clinical and short-term empirical), I can’t help but point out one final reason why we’re not talking about the long-term outcome and brain science evidence above.
The powerful influence of mental health advocacy groups. A final reason we’ve been dissuaded from taking up a broader mental health conversation about long-term outcomes is both simple and troubling. Some of our most dominant (and well-funded) mental health education initiatives have directed our attention away from these possibilities – focusing instead on ideas that reinforce a central focus on medical treatment as a lasting, long-term need.
As part of his investigation into the drug industry’s influence on the practice of medicine, Senator Charles Grassley required NAMI and other patient advocacy organizations to reveal their ties to drug and device makers. NAMI disclosed that 75% of their revenues had come from pharmaceutical companies, with pharmaceutical companies donating nearly $23 million to the alliance over the course of three years alone (2006-2008).
While this doesn’t necessarily mean the educational efforts of organizations like NAMI are suspect, other examples of its own popular Family-to-Family Educational class illustrate how they have played a large role in setting up a very particular mental health conversation. This class, which has arguably been successful in reaching most families facing mental illness, includes an accompanying 495-page manual provided to participants.
In a word count of the large class manual, I searched for major interventions available for mental/emotional distress. In the nearly 500 pages of text, the following table summarizes the mention count:
- Meditation: 1 time
- Physical Exercise: 5 times
- Diet: 11 times
- Psychotherapy: 76 times
- Medication: 228 times
This is not about getting wacky with conspiracy and painting some dark picture. But it is about becoming aware of where our health information is coming from…and the degree to which this information has been influenced by industry. It’s one thing for people to take medication thoughtfully (which is fine). It’s another thing to have the makers of those medications educate us all about mental health (which is not fine).
But that’s precisely what has happened. And I would argue that partly explains why our public mental health conversation today hardly ever focuses on the question of longer-term outcomes (or brain changeability or mindfulness or nutrition or exercise or spirituality, for that matter).
Due in part to the limited awareness of the foregoing, the NAMI story of mental health has been widely – almost universally adopted – across institutions in the U.S. and increasingly abroad. This is evident pretty much everywhere you look – including in my own beloved faith community.
LDS Mental Health Education Initiatives as a Case Study
In what follows, I shine a brief light on some of the more prominent influences on my own faith community coming to adopt (essentially) the same mental health narrative as the rest of America. Like leaders of all communities (including faith communities), it’s clear that LDS church leaders are wrestling with these questions and trying to do whatever they can to help.
Alexander Morrison’s mental health teachings. In 2005, I met Elder Morrison at his home to discuss our common interest in mental health issues. As my stake president once told me, in the absence of more official direction, Elder Morrison’s book and articles had been read over a decade by many LDS leaders as the “voice of the Lord” about mental illness.
As part of his professional training, Elder Morrison received a master’s degree in pharmacology. No doubt the most influential influence on his thinking, however, was witnessing the painful experience of his own daughter Mary over many years. In his book, he relays the story in her own words, starting with a stressful move to another country where his then-16-year-old daughter found the new school system to be extremely difficult. This situation prompted for his daughter some serious struggles with fear, where she felt paralyzed and unable to move forward.
That’s when, as she puts it, “the first signs of my severe psychological disorder appeared” – with an accompanying confusion she acknowledges at the time, with the family asking “what is happening to you?”
Mary continues: “It took time and patience and visits to several doctors before we finally found solid answers,” including a medical diagnosis for what was happening: “panic disorder with agoraphobia.” She writes, “I remember my feelings as I heard those words: acute relief mixed with alarm. The diagnosis sounded serious, severe. I was right.”
Despite this alarm, Mary remained hopeful. A diagnosis, she reasoned, ought to point toward healing possibilities: “Finally I could be cured, I thought…I moved forward with hope, but I would soon learn that for me a correct diagnosis wouldn’t necessarily result in a cure.”
She describes what happened next. After starting an antianxiety drug, she felt optimistic enough to return to school and began doing well academically again. But then, she writes, “I fell apart emotionally. I spent hours huddled in my parents’ closet in tears. Twice I blacked out, and I began trembling and shaking.” She was admitted to the hospital and with a new course of medication and additional support, left “more stable than I had been for many months.” This again led to a “temporary surge of optimism” and a hope that “surely I must be getting well.” She said, “I entered school again, and once again, within months, my life began to crumble. The panic. The terror crashed in on me.”
Mary writes in retrospect, “It’s been almost five years…and frustratingly little has changed.” She goes on to talk about severe bouts of clinical depression and signs of other problems.
Mary’s story is like many others I’ve heard. In fact, her story reflects such a common pattern that we may miss what might otherwise be obvious: namely, how precisely it mirrors the evidence pointed out in the last section: chronic medical intervention, followed by a prolonged (and worsening) course of illness.
Since that larger pattern is not something we’re even aware of, however, it’s not surprising that it hasn’t figured into Elder Morrison’s writing, which has instead focused on promoting the same psychiatric approach that his daughter had received. Over the years, Elder Morrison did more than anyone to popularize a NAMI-aligned approach among Latter-day Saints through his 2003 book “Valley of Sorrow,” and associated Ensign Articles.
Does God want me on meds? In October 2013, Elder Jeffrey Holland spoke more directly on mental health in a historic general conference talk. Like always, Elder Holland’s talk was nuanced, multifaceted and heartfelt. He spoke powerfully of the crucial need for a broad approach involving lifestyle adjustments, the power of agency, scriptures, prayer and relationships.
Despite all this, a single paragraph in Elder Holland’s talk has been repeated and emphasized more than any other: “If you had appendicitis, God would expect you to seek a priesthood blessing and get the best medical care available. So, too, with emotional disorders. Our Father in Heaven expects us to use all the marvelous gifts he has provided in this dispensation.”
Wow. Did an apostle just say that God expects me to get on Prozac?
No, not exactly. But that’s precisely how I would argue it was interpreted by tens of thousands of Latter-day Saints. The day after the talk, I received a text from one woman describing the pressure she felt almost immediately to get on antidepressants.
And in the years since, I’ve been struck at how often the continuing conversation about Elder Holland’s powerful talk has centered to a great degree on that single paragraph. For instance, on June 20, 2016, this same paragraph became the centerpiece of a composite video on mental illness featured on the Mormon Channel.
If you had appendicitis, God would expect you to seek a priesthood blessing and get the best medical care available. So too with emotional disorders. Our Father in Heaven expects us to use all the marvelous gifts He has provided in this glorious dispensation.
Later that same year, in September 2016, Eric Murdock from Church Magazines highlighted that same paragraph in an article called “Dealing with Depression”:
Your depression may need to be treated with medication and therapy from a professional. There’s nothing wrong with seeking professional help; in fact, it can be a really good thing. Elder Jeffrey R. Holland of the Quorum of the Twelve Apostles has explained, “If you had appendicitis, God would expect you to seek a priesthood blessing and get the best medical care available. So too with emotional disorders. Our Father in Heaven expects us to use all the marvelous gifts He has provided in this glorious dispensation.”
And more recently, in September 2017, this same paragraph was featured in a Mormon News Room news release for national suicide prevention month:
Elder Jeffrey R. Holland called for both spiritual and professional help when dealing with mental illness: “If things continue to be debilitating, seek the advice of reputable people with certified training, professional skills, and good values. Be honest with them about your history and your struggles. Prayerfully and responsibly consider the counsel they give and the solutions they prescribe. If you had appendicitis, God would expect you to seek a priesthood blessing and get the best medical care available. So too with emotional disorders. Our Father in Heaven expects us to use all of the marvelous gifts He has provided in this glorious dispensation.”
God. Expects. Us. To. Use. ALL. Of. The. Marvelous. Gifts.
Perhaps it’s unsurprising that this line and its surrounding paragraph has received far more attention than any other. Occasionally over the years, endorsements of psychiatric medication as central to healing have appeared in Church publications, with Elder Morrison in a 2005 Ensign article giving an especially glowing evaluation of the potential of these treatments.
But to hear an apostle endorse this approach (as a kind of gift the Saints were expected by God to receive)…well, that was big news!
Since that talk, the overall LDS mental health website has carried an underlying message very aligned with groups like NAMI. For instance, there are mentions of permanent biological deficiency in multiple video interviews on the site:
- “And after our second counseling session, she just told me, she said, “There’s nothing you need counseling for. This is all chemical. You just need to get on the right medication.” (Alan’s Story)
- “I definitely have felt broken, and I think I’m coming to recognize that I don’t need to feel that way. I remember, after my freshman year, telling my mom that I just was broken and there was something wrong…Just feeling especially like you just can’t control it, and it’s chemicals, and so that kind of makes you feel broken….It is a chemical thing… it is a physical reaction to chemicals in my mind.” (Cassidy’s Story)
- In one short Ensign article referenced on the website, the author mentions the “chemical imbalance” theory four different times.
Note: While these videos and articles have been posted on official LDS websites, it’s important to acknowledge that the LDS Church has not officially declared any of them to represent official policies or positions. Once again, clearly this is an issue being wrestled with by leaders and members of the Church.
Implicit treatment recommendations. At the beginning of every video on the LDS site, it states explicitly, that this is “not intended to recommend a specific treatment model.” While that disclaimer is welcome, it’s also pretty clear that people will take away specific treatment advice, given the clear themes and patterns that run throughout the videos (and the other Ensign articles referenced on the Church mental health site).
In other interviews available on the LDS website, there’s frequently a sense that seeking medical support can and should be a first-line intervention – and that with persistence, people will definitely-and-eventually find one that works. For instance:
- “A stake president had counseled us, if someone comes in with that kind of thing, to get them in to a medical professional quickly so that they can get diagnosed and get the help they need. And so, I counseled her to do that.” (Alan’s Story)
- “I went to a doctor and, you know, explained what was going on. And we tried some different prescriptions until we found one that was working, and that’s great. It took a little trial and error to find something that was working.” (Jesslyn’s Story)
Rather than explorations of one treatment possibility, there’s a clear sense in several videos that certain mental health conditions will likely be more awful and devastating if people do not seek the right treatment (and stay on it). There is special emphasis given to the conviction that these treatments are undoubtedly safe, effective and also (most likely) needing to be long-term:
- “Medication was a stigma to me. I never thought I’d be dependent on medication. And so [since he hadn’t yet fully accepted this treatment] it didn’t end. It continued on and continued on.” (Alan’s Story)
- “Because I started taking medication maybe three years after when I saw that along with the bipolar, I’d be very up and down, and changing my mind a lot about things, so not being able to function properly without medication.” (Kitengie’s Story)
- “It is a chemical related issue – and he’s prescribed me a number of medications that help with different features of it.” (Ryan’s Story)
Some of the Ensign articles referenced on the same website reaffirm long-term psychiatric treatment as essential to well-being. These are the kinds of messages and videos that we’re sharing with millions of members of the Church to provide inspiration and direction.
By a long shot, these aren’t the only emphases on the LDS mental health site, with many powerful witnesses of Jesus’s power to heal as well. These are so frequently juxtaposed with narratives of lasting deficiency and life-long disorder, however, that at times it makes for an awkward and confusing overall message.
Can Jesus heal me? Throughout the many videos shared on the site, there are many wonderful witnesses of Christ and testaments to his power. For instance, one woman said: “I knew I wasn’t alone, and I didn’t have to be scared anymore. You can feel like you’re in a pitch-black room with no hope -and all of a sudden, he’ll give you that hope. He’ll give you that comfort. It doesn’t matter what you’ve done, or what you feel like you’re worth. He’ll always love you. And I know that. I’m enough, because I’m his. My value is more than I can even fathom.” (Bethany’s Story)
Virtually every story contains similar beautiful testimony and messages that attest to Christ’s power to heal – which, alone, is a legitimate and wonderful comfort.
In the same interviews where people speak of Christ’s power to deliver, however, it’s hard not to notice how many of these people acknowledge and admit their own problem isn’t going away much:
- “I still deal with it on a daily basis” (Alan’s Story)
- “The success hasn’t been overcoming it completely…the success has been learning to manage it and to live with it.” (Leilani’s Story)
- “The depression started my junior year, and it’s been like that ever since. And it usually gets worse.” (Kitengie’s Story)
- “So, it was really hard for me to accept the fact that this is my thorn in the flesh, this is my life.” (Regi’s Story)
- “The spirit also told me ‘it’s not going away…This is yours’…okay, if this is mine, then I’m going to learn how to manage this.” // “No matter how bad it gets – it gets bad. I’m not going to take away from that. It’s bad, and there’s just no vocabulary that I have to express the depths of despair.” (Sheryl’s Story)
- “I’ve had this condition for about 20 years…the reality is it’s a chronic thing that keeps coming back.” (Ryan’s Story)
- “Mark has struggled with depression most of his life…I had prayed most of my life to feel better – and those prayers were not answered. And it was so discouraging.” (Mark’s Story)
- “It’s an ongoing battle” (Craig’s Story)
The combination of these two messages at times make for an awkward and uncomfortable fit. On one hand, beautiful testimonies are heard throughout the site, such as this 2006 statement from Elder Oaks:
Jesus healed many from physical diseases, but He did not withhold healing from those who sought to be “made whole” from other ailments. Matthew writes that He healed every sickness and every disease among the people (see Matthew 4:23; 9:35). Great multitudes followed Him, and He “healed them all” (Matthew 12:15). Surely these healings included those whose sicknesses were emotional, mental, or spiritual. He healed them all.
On the other hand, over and over, it’s stories of chronic, lasting illness that are featured. Indeed, it’s been difficult to find any clear examples where people actually get better long-term and find lasting healing.
As a result, it’s hard not to feel a lingering sadness and heaviness to the site, accompanying it’s hard-to-deny overarching message: We know Christ can provide healing…but we haven’t really found as much of that as we have hoped.
Over and above the raw mental/emotional distress many people continue to face, this specific tension can generate an additional burden. Elder Morrison’s daughter Mary writes about pleading to God: “Dear Heavenly Father…please take this illness from me. I have been sick for four years. I look around at the people my age and see them achieving everything that I dream of: school, marriage, a career. I am disabled. I know nothing but intense pain. Why is this happening to me?”
She recounted, “I spent many nights crying and begging the Lord for relief and help. A loving Heavenly Father answered my prayers – not with the healing that I so desperately prayed for…my problems haven’t been taken from me.”
A woman who had lost her husband to suicide shared poignantly during her interview her heart-breaking wonderings in the time since: “I wondered why God would put my family and my children in a position where they didn’t have a Dad…I don’t know why God is letting us experience the loss of my husband: why he couldn’t get better.” (Melinda’s Story)
And another man states, “I had prayed most of my life to feel better – and those prayers were not answered. And it was so discouraging.” (Mark’s Story)
I’ve seen this same aching conflict and discouragement poignantly experienced in the lives of my own loved ones facing mental illness for years and years. And in most cases, this eventually becomes accepted as simply a part of the painful reality of long-term disability associated with serious mental illness.
This essay is my own plea – translating the evidence into the language of my own faith community – to consider another possibility.
Why can’t people get better? Why are prayers not answered, despite the most desperate and earnest of pleas?
It may well be that God is saying NO to the earnest cries of these hearts. That is something that all believers have to be humble enough to receive.
But what if we’re missing something – and haven’t yet received the full truth on these matters? What if there’s a lot more light and knowledge yet to hear that could move us toward more sustainable outcomes? And what if the answers we are currently putting our trust in, simply aren’t doing the job?
Part of the hard message I’m delivering here is that some of these awful, heartbreaking outcomes shouldn’t be surprising…not if we’re paying attention to the long-term evidence referenced above. If that set of evidence is to be taken seriously, then we have to take seriously the possibility that the approaches and narratives we have adopted are inadvertently, unintentionally, over time (and largely beneath our awareness) contributing to this epidemic pattern of longer-term despair and disability.
Please don’t turn away from that possibility. It’s too important to ignore anymore.
To be clear, there may be some people who cannot find that healing – for different reasons. For instance, one woman said, “It wasn’t the Lord’s will to heal me in this lifetime. This was my thorn in the flesh. This was meant for me.” (Regi’s Story)
That’s a possibility we should respect and acknowledge, so as to not create unrealistic or naïve expectations. And to be clear, none of the arguments above intend to deny the reality of enduring suffering for so many.
It is not the lack of attention to long-term suffering that is our danger, however. The concerning question is why no one is hearing about anything but long-term chronicity and why this is being presented to everyone as the likely and expected prognosis (for ADHD, schizophrenia, bipolar, depression, severe anxiety, etc.). Indeed, it’s become very rare for me to meet anyone who is aware of the possibility of long-term healing!!
Overlooked science that could confirm our hope. If this possibility of sustainable, lasting healing from mental illness was being advanced by fringe groups of hippies, new age thinkers OR if there was limited research confirming that possibility OR if our current approaches were leading people to lasting healing, all of this concern would be understandable.
But as reviewed above (and below), NONE of this is true. Laying aside the concerning patterns noted above, there is a great deal of evidence (of many kinds) that could bolster our hope in lasting healing across even serious mental/emotional conditions. The proponents of these possibilities represent some of the most respected thinkers in psychology, neuroscience and medicine, drawing on literally hundreds of studies.
One organization that has been a gathering point for many of these people is the Foundation for Excellence in Mental Health Care, led by Gina Nikkel and comprised of generous donors sponsoring many important recovery-oriented projects. In addition to the neuroscience and genetics evidence reviewed earlier, we are seeing in society today many studies on exercise, nutrition and meditation applications for mental health that confirm bright hope.
All that being said, for those looking for alternatives to a longer-term treatment regimen, it’s not always clear what (exactly) they could do differently. At a presentation I attended on the consequences of long-term Ritalin use, the psychiatrist sharing was asked by a participant in the back: “if we don’t keep children with ADHD on Ritalin long-term, what else are we going to do?”
With somewhat of a baffled look, this man said “ALL OF LIFE! Nature – and relationships – and exercise – and good food – and sunlight – and trips to see the world – and playing games…”
Have we lost our imagination at what is possible? The answer is, yes!
Surprisingly few people realize that the medical research also confirms literally hundreds of potential contributors to depression – each suggesting a possible point of intervention and adjustment (aka, hundreds of things to potentially move in a direction of long-term healing). Our non-profit has documented a similar broad set of potential contributors for ADHD and other conditions – and are working on completing similar inventories for anxiety and post-partum depression.
These inventories are not intended to establish “causes,” as much as raise awareness of the striking range of possible contributors in the world around us (reflected in the lifestyles we end up taking up).
The good news is this: As people make relevant changes and adjustments, they have every reason to expect that the emotional experience can alleviate. Let’s start telling people THAT!
I will never forget the first moment that one woman heard this in my depression class After taking our survey, she exclaimed, “I have 9 risk factors!”
She was overjoyed…but why?
Because there were things she could do (things that can predictably decrease her vulnerability to depression over time).
That’s a message that is deeply consistent with Latter-day Saint teaching on agency and Christ’s power. But not only is it not the message that people with mental illness often hear, it’s the opposite of what they are frequently hearing.
Minimizing personal responsibility and choice. One of the most common messages told to those facing mental illness is that this is not your fault! There’s nothing you could have done to prevent this (nor will your personal choices or effort be paramount in getting out). The same pharma-funded patient advocacy groups mentioned earlier have underscored this notion for years, for instance:
- “Mental illnesses are biologically based brain disorders. They cannot be overcome through ‘will power’ and are not related to a person’s ‘character’
- or intelligence.”
- “Mental illnesses are not the result of personal weakness, lack of character or poor upbringing. No one is to blame.”
Within an educational context this kind of message is repeated over and over, it’s unsurprising to find those facing mental illness essentially picking up this same language. For instance:
- One woman spoke of her brother trying to help her realize that depression “didn’t have anything to do” with her efforts and that recovery didn’t rely on her making any changes.
- “This isn’t your fault” another person facing depression was told by a friend, “there is this chemical in your brain that says you can’t be happy and content.”
- Another woman expressed gratitude for realizing that “there was nothing I could have done to keep me from getting depression…I mean, it’s not like if you don’t smoke you won’t get lung cancer, you know? I mean, it’s not that kind of a thing; you can’t say, ‘well, it’s because I ate the wrong thing, you know…it couldn’t be helped.’”
Within a faith community where personal agency and responsibility is so highly prized, all this becomes another potentially confusing message and conflict. That’s why it has been disheartening to see our LDS mental health education initiatives adopt essentially this same narrative of choice. From my review, even though the value of lifestyle adjustments is often acknowledged, there’s a subtle, but consistent minimization of how much personal choice and lifestyle adjustments can do for you in the healing process.
Alan’s story reads like a cautionary tale in this regard: “As a young bishop Alan thought a healthy lifestyle coupled with strong religious habits could ‘fix’ depression. After experiencing it for himself he develops a deeper understanding of mental illness.”
He recounts counseling with a woman as a Bishop, “I kept trying to question her and ask what was causing this, what was bringing on this darkness.” He adds, “I remember thinking, ‘If she can drink more water, eat healthier foods, exercise, get better sleep, that kind of thing, that she’ll get better from this.'”
He relates these thoughts with some level of regret, as an expression of his prior naiveté: “And I was insensitive to her, and I didn’t mean to be. I didn’t know how to react and how to help her.”
That same naivete figures into his own story: “Right when it began, when it was really severe at the very beginning, I remember thinking, ‘If I read my scriptures, it will go away.’” (Alan’s Story)
As reflected here, these messages of personal change and responsibility are often framed as deeply naïve. For instance, after speaking about the challenge of depression, one woman claims the following about what others sometimes say: “And yet we just tell them, they should just suck it up, and power through, and if you just tried harder, it would be okay. But you would never tell the same thing to someone with diabetes” (Melinda’s Story)
She goes on to underscore the profound naivete of suggesting someone could grow and heal from unmedicated effort: “But you would never tell the same thing to someone with diabetes – you’d never ask them to go without medication. You’d never say ‘and just try harder without that insulin and it will happen.’” (Melinda’s Story)
Surrounding emphasis on agency is portrayed as out-of-touch and unenlightened (as to the true nature of mental illness):
- “One of the hardest things for me to hear was ‘if you read more scriptures and you said your prayers more, you’d be better.’” (Sheryl’s Story)
- “My family would say, ‘Well, you’re not depressed. You just need to pray. The Lord is going to help you. You don’t need medicine’” (Kitengie’s Story)
Overall, the message is this: Lifestyle is important…but not really. That’s not really what matters for the illness. Scriptures and prayer are important…but don’t overdo it or get your hopes up with that.
What I’m pointing out here (first in relation to brain science, second in relation to recovery, third in relation to agency), is a striking tension (and awkward fit) between core hopes of the gospel and the NAMI-aligned messaging that has infiltrated our own faith community. More than an intellectual tension, however, all the foregoing has very defined and concrete consequences for choices individuals and families make.
For example, one woman who had been making progress in my own mindfulness class learning skills to help work with painful thoughts and emotions, was told by her physician priesthood leader that it was naïve to invest too much attention in mindfulness, and that what she really needed was something more. This persuaded her to effectively abandon mindfulness and begin instead a course of longer-term medical management relying on multiple psychiatric medications.
Learned hopelessness. It’s true that some find the messages of brain deficiency and there’s-nothing-you-could-have-done/not-your-responsibility relieving and even liberating. NAMI has shared for years that people will feel better to know that their own choices had nothing to do with the development of mental illness.
There’s also evidence to suggest, however, that this message can actually make people feel somewhat disempowered, with those who embrace a view of their own brain as deficient ending up seeing their own prognosis as worse and feeling more pessimistic about the role of other non-medical treatments as being effective (something I observed in my own interviewing study as well). For instance:
- In her 2005 research on women with depression, Dr. Helen Vidler, a psychiatrist in Australia, also notes that “a sense of being stuck in an enforced withdrawal or hibernation permeated the majority of the women’s descriptions of depression.” “Participants’ statements” she continued, often “referred to feelings of helplessness, powerless, and an inability to take action, or feeling they were not in control of their lives.”
- In their 2007 discourse analysis of newspaper representations of mental illness, for instance, one research team noted a pattern of “people with mental health problems” being framed in the prevailing treatment discourse “as passive sufferers of their condition.”
- A 2009 study by researchers at the University of Wyoming concluded that some of the brain deficiency messages common to stigma-busting campaigns can lead to “a worse expected prognosis, and the perception that psychosocial interventions would be ineffective.” They conclude that “The chemical imbalance explanation appears to reduce blame at the cost of fostering pessimism about recovery and the efficacy of nonbiological treatments.”
It was one of the founders of the “Positive Psychology movement,” Martin Seligman, at the University of Pennsylvania, who famously spoke of the explanatory styles that reflect how people explain to themselves why they experience a particular event. Based on his criteria, this dominant view of mental illness reviewed above reinforces an explanatory style that is both very personal (my brain is at fault) and permanent (this will be a stable challenge).
This perhaps explains why a new diagnosis that take for granted this kind of a fundamental biological deficiency can be a sobering and deeply transformative experience personally. One woman I interviewed who had newly accepted this disorder in her brain, said this:
You feel like you lose yourself, almost. Like a part of you dies when you’re diagnosed…like a grieving period realizing that the person that was faking it for so long – she wasn’t real….and that we had to reinvent and restructure this new being, almost…Giving her the tools and the revenues, making sure she had insurance all the time…it’s hard [you] do feel a detachment from everything you thought you were when this becomes where you’re at.
In this way, individuals may come to see themselves as having little potential of meaningfully impacting the going or coming of mental disorder. The one exception may be in relation to treatment management, cooperation and compliance, where individuals are often encouraged to maintain resolute commitment to a treatment regimen attempting to extinguish or control troubling emotions and thoughts.
It’s as if we’ve forgotten that deep and lasting is even possible.
Bottom line: Those distressed individuals who adopt society’s dominant view of mental illness can often come away feeling substantial despair. At times, this effect can be almost immediate. One young woman told me, “My suicidal thoughts started the same day my doctor told me that my depression would be life-long.”
To further illustrate the felt consequences of this subtle socialization, check out this short video on Learned Hopelessness.
In the absence of an awareness of longer-term possibilities of healing (and personal power to move in that direction), we do our best to provide some kind of real hope.
One day in the resurrection. I remember sitting at an AMCAP (Association of Mormon Counselors and Psychotherapists) conference years ago, where the speaker assured everyone that “one day in the resurrection people will find healing from mental illness.”
The speaker was intending to offer a hopeful, uplifting message. But for some reason, I felt sick to my stomach – as if we were all being invited to accept that, in essence, these people won’t find healing until the resurrection.
This is a common sentiment – and for me, at least, has been painful to witness at times. One young woman spoke about “trying to gain an eternal perspective.” She said, “At the end of the day these illnesses…They are only until we die. And after this, there will be a resurrection -and there will be a glorious day when I’m going to be so perfect.” (Cassidy’s Story)
In one 2001 Ensign article, Dawn & Jay Fox write, “We know that everyone will one day be resurrected with perfect bodies, including brains that are free of structural or functional problems. Our challenge, then, is to help those with afflictions that are not healed during mortality.”
As reflected above, it’s often taken for granted that the mental illness will be inevitably chronic and painful in this life. The parent of a daughter with schizophrenia were quoted in the same article as saying: “When I realized the true impact of my daughter’s illness on her life, I lost all hope. That was a very dark and helpless place. But as I allowed others to reach out to me, teach me, and offer me their strength, my hope was restored.”
As reflected here, the focus of efforts goes not toward seeking lasting healing, but instead toward enduring well the long-term burden. The same article goes on to make the following recommendations in how to help others accept this trial and manage this pain – each suggestion presuming a burden that will likely remain a part of a family’s life for a long time. The authors summarize part of the message they sincerely intend to be hopeful as follows: “While all health problems will not be healed during mortality, individuals can often find hope, improvement in some areas.” 
While the desire to provide hope is sincere, I’m pointing out serious limitations to that hope, derived from the larger narrative implicit in so many of these messages. One way to summarize the main point is this: many people facing intense sorrow are hearing (and being told) a very depressing story about depression: namely, your brain is fundamentally deficient, you will likely struggle the rest of your life, and you will likely need auxiliary medical support the rest of your life.
While some of these ideas can be relieving at first (especially that something serious underlies their struggles and that something can be done about it), there is abundant and growing evidence that this story and approach over the long-term can inadvertently lead people to a place of disempowerment and helplessness.
Looking Forward to Possible Adjustments
One takeaway from the foregoing is an invitation to rethink some of our most common mental health beliefs – including some ideas we treat like reality, rather than one way of thinking.
Getting help = being okay, right? For instance, there’s a sincere and earnest belief that if we get people into treatment, if we can get people early and quick access to care, they will be okay. From this perspective, as long as someone truly understands their condition and gets help as soon as possible, the suffering will decrease.
Connected with this conviction, once someone starts on medications, families can arrive at an honest conclusion that as long as their loved one will be compliant and stay on meds, they will be okay. Thus, one man describes his friends asking him when things get bad, “Hey, Ryan – would you please try your medication again. Let’s see if that helps.” (Ryan’s Story)
Honestly, how nice it would be if people’s well-being could be as simple as making sure they got the right treatment and then stayed on their medication! This paper represents a plea to reconsider ideas like this that we’ve taken for granted (and consider some others we’ve mostly ignored).
It’s often the realities that are farther off (and harder to see) that we’re not giving enough attention. For instance, Dr. Richard Ferre, a psychiatrist involved in the missionary mental health efforts, says the following about a missionary facing intense mental/emotional distress: “With correct medication and intensive psychological intervention, Elder Smith improved remarkably over the next three months.”
That’s essentially where the story ends. But what happens a year or three later? How is he doing now?
We’re not talking about that! (enough) It’s kind of like a love story where the audience sees the dramatic action right up until the moment of greatest passion and romance. While all that may be welcome and beautiful, there’s far less attention given to the realities that follow the Great Big Amazing Kiss: is there any lasting happiness found together?
While it’s true that we don’t always “think long-term” in American health care, perhaps we need to start. I would argue that’s the one thing we must do above all: taking far more seriously than we currently do, the long-term picture. Isn’t that kind of what Jesus was getting at in his cautionary line, “by their fruits ye shall know them”? (aka, pay very careful attention to the true outcomes associated with popular teachings in society).
Treatment vs. healing. I am pressing the point here for a reason. As abundantly illustrated virtually everywhere you look, in lieu of lasting healing and recovery, what is frequently being held up as the aspiration to seek after is ongoing medical management – a distinction that Daniel Fisher at the National Empowerment Center first raised. Most people seem to hardly differentiate between the two, with treatment and healing becoming synonymous, and disease management and recovery one and the same.
Thus, Dr. Richard Ferre wrote the following about an experience he had trying to help an Elder who had returned home early be able to “heal and learn how to take spiritual power over his temporal state.” Clearly seeing his words as aspirational and empowering, Ferre wrote, “The time was now available for him to understand the nature of his inherited illness and what treatments might be effective in managing his illness for the rest of his life.
If it felt empowering to this well-meaning physician, I have to ask how this message felt to his returned missionary patient?
Consider this comment from the mother of the man mentioned earlier (who was told by a psychiatrist on his mission that that he needed to be on medication for the rest of his life). Reflecting on her son’s subsequent experience of psychiatric treatment over many years and the devastation he initially felt upon hearing this definitive and authoritative conclusion, she told me:
An individual who feels they have no option but to “stay on medication forever” and endure the side effects is an individual who feels they have no control over their life, and no hope. That same individual who is empowered with information about all the options available, and not feeling pressured to being on medication forever, is an individual who has hope for their future because they understand they have choices/options. They can choose when they want to try to go off medication. They don’t feel “stuck,” they feel EMPOWERED. That is what gives them hope.
Is that a hope we can provide to more people facing mental illness? Are those choices and options that we could better ensure people have available?
In the absence of more focused attention on reasons for sustainable hope, I fear that large numbers of people continue to hear (and adopt) a larger narrative that can end up weighing on them tangibly: permanent biological impairment, life-long problem, unending medical management, etc.
That, in essence, was the conclusion of my entire dissertation study. People suffering + despairing story about their suffering = worse suffering (especially over time as they follow that story out).
Perhaps something as simple as clarifying the difference between ongoing treatment and lasting healing could help people. As mentioned earlier, with diverse colleagues (including one in conventional psychiatric care), we published a paper diving deep into these distinctions in 2014.
As we illustrate throughout that paper, this is no academic, merely linguistic distinction: with very real, aching consequences for real lives on many levels.
Hitting the ceiling. In particular, when people are not aware of the distinction between treatment and healing, what you end up seeing is great confusion when the treatment doesn’t reflect healing. Thus, we again see faithful followers of Christ reaching for the Savior earnestly and sincerely and experiencing the mental anguish of not finding the deliverance they assumed He could offer.
Virtually none of these people consider that rather than facing an insurmountable problem, they may, in fact, be on an unsustainable path of healing: one that simply limits the recovery possible.
I’ve seen many examples of this: for instance, the teen in my meditation class while on an anti-depressant, who did all the exercises faithfully and diligently week after week, but couldn’t ever feel any progress. Or the woman with a decade of anti-depressant use, who signed up for our Utah trial of a British-developed 10-week rigorous exercise program for those with depression. Although she participated faithfully and consistently (and while literally everyone involved felt a boost), she struggled to feel any significant emotional benefit from the consistent exercise.
Referencing back the aforementioned literature on anti-depressant outcomes, it seems that there’s a ceiling on healing that people medicated long-term can’t punch through physiologically, limiting the healing they are able to find.
This is not to be negative. Rather, it’s a call to realism (and more attention/study) on potential limits we’re placing on people when asking them to accept a path of long-term medication management. But please don’t forget: there’s another message of great optimism in this all, in regards to what might well be beyond these artificial limits. For many scholars involved in this broader conversation, this also stimulates fresh questions for how to best facilitate healing.
For instance, similar to working with the laws of the body to heal, what are the laws of the mind we need to better understand to invite profound and lasting healing? As Mark Williams & Jon Kabat-Zinn note in their book, “the mind does not like to be forced – and if we try, we might like what comes of it.” They continue, “When we stop trying to force pleasant feelings, they are freer to emerge on their own. When we stop trying to resist unpleasant feelings, we may find that they can drift away by themselves.”
Contrary to perceptions otherwise, the good news is that a great deal of recovery that can happen naturally – especially among those who are able to taper off medications. (Check out Robert Whitaker’s summary of this good news confirmed by both the long-term and historical evidence):
But those who stay on psychiatric medications long-term cannot expect to find the same level of healing.
They just can’t.
This is not merely someone’s opinion. Both of those conclusions come through strongly in the long-term evidence reviewed earlier.
Deflating or exciting? To many, this analysis above may be energizing and confirmatory of a deeper sense they may have carried. It also may be relieving to have another way to look at why the burden of mental health problems continues to worsen despite all of our hard work and efforts.
To others, this same analysis will be discouraging…especially since the very approach they have worked to promote and the very message they hoped would help, ultimately (and over the long term) is turning out for many to be discouraging people and leading them to increasing chronicity of struggle.
Not only would that be painful to hear, it’s highly likely people will react to it as unthinkable – and much easier to reject outright.
Once again, please don’t do that.
Do no harm. Doctors, nurses, counselors, parents, especially: please don’t ignore this evidence above.
Please don’t turn away.
While these conclusions may feel threatening to some of what you offer professionally, try to remember whose well-being is threatened most if this is true? (and what the full truth might positively mean for them).
One doctor who read Robert Whitaker’s book summarizing the long-term evidence threw it across the room enraged. He later he told an audience: “But I couldn’t deny the evidence in the book.”
Yes, it’s a scary possibility. If it’s true, it means we may need more than minor adjustments to our approach. Some major course corrections may be in order.
But is there any legitimate alternative to at least taking these possibilities seriously?
How dare you. I had a doctor scold me once that these were questions only professionals should address: How dare you say these things publicly. Do you know what kind of questions that might raise?
To any who might feel like this doctor, I would say that given the intensity of suffering, how could we not raise these questions publicly? If all the above is true, how dare we not tell people?
It’s worth pointing out that within the current American conversation about mental health, anyone who questions either the diagnosis, its permanent biological basis or its medical treatment (or who suggest personal choices and responsibility are more central than we realize) are “reflecting stigma,” which continues to be presented as the greatest threat and barrier to relieving mental illness today.
Beware anyone who equates serious critique like this with fanaticism or extremism. This is a long-established technique of propagandists over history – no doubt, because of how effective it is to stifle dissent.
Especially given the real-life pain of this issue, I believe there is no other alternative but to take these possibilities seriously.
The reality, as illustrated above, is that some of our prevailing and most widely accepted assumptions conflict directly with existing long-term evidence.
Despite this, these possibilities above continue to be hardly on our radar. Indeed, when this perspective comes up, it still seems a shock.
Understandable family worries. In particular, I acknowledge that this message can be shocking and scary to dedicated parents and caregivers, especially when they’ve spent so much energy convincing a child or other family member that they should NOT ever consider going off their meds.
For these families, they may be among those sincerely convinced that their loved one’s well-being is dependent on their long-term compliance – a conviction that may influence very different reactions to this message. I’ll never forget a conversation I had with a mother and her daughter who was facing some serious mental health issues. As I reviewed some of the reasons for why this girl may be hopeful for lasting healing to the point where she may not need to be on her heavy psychiatric regimen forever, this young woman noticeably (and immediately) brightened up, clearly refreshed by the thought. In the same moment, however, her mother was horrified that her daughter had even been exposed to such an idea.
And I understand why. No doubt, her mother was trusting in the idea that her daughter’s long-term stability (for a condition she clearly saw as life-long) was dependent on ongoing medical compliance. Anything that unsettled that larger belief was experienced as a threat.
But is it really? From where is the true threat to long-term well-being coming?
Given the many year of treatment many people have experienced, let’s admit that these are not easy questions and there is a lot of complexity to the right decision for each individual and family moving forward. In this video below, Robert Whitaker summarizes some of his own takeaway insights for families with someone facing mental or emotional distress: Messages to Families Facing Mental Distress].
What is the real danger? Clearly, it’s not time for everyone to taper off a psychiatric medication – since for some, continued treatment may be necessary to their current stability and well-being, for different reasons. I acknowledge that here, and agree that it would be unethical not to be clear about that.
However, to not acknowledge the other possibility – that long-term use may be deleterious and that tapering may be beneficial for people’s healing at some point – is I believe equally unethical.
To state the question plainly: Is it dangerous to let people know of the possible benefit of deep, long-term healing available (and not exclusively dependent on medication) or is it dangerous NOT to inform them of this?
In a historical moment when one in 10 Americans (and one in four middle-aged women) is on an antidepressant and still the burden of chronic mental illness is accelerating, the last thing we want to do is foreclose fresh possibilities. Indeed, the possibility I raise here could be phenomenally good news for people who have experienced unremitting mental health problems for years. Instead of looking forward to yet-another-year of simply “managing or coping with their depression,” this at least invites a conversation about higher levels of well-being that may be available.
Sincere and wonderful intentions. It’s important to always remember that everyone involved in supporting those facing these problems is doing the best they can, with the best of intentions. This is also not about delegitimizing actual experiences, any more than my critical review of Mama Dragon narratives aims to question the reality of their own pain. What both are trying to do is surfacing (largely hidden) patterns that are relevant to the common goals everyone shares: safety, well-being, mental health, happiness, etc.
And in both cases, I reach precisely the same conclusion: the dominant narrative being adopted by many families is causing harm…especially when you trace out the implications long-term.
Living out a story. The long-term evidence noted above is surprisingly consistent. Based on that, let me be clear about my own principal concern. What I’m raising here is the possibility that we are effectively ushering hundreds of thousands of Mormons into adopting a certain narrative and treatment paradigm that virtually all of the long-term evidence suggests will lead people to a darker place if lived out for many years.
Because we are largely not aware of the foregoing, however, most people take for granted that what they are hearing about mental health online is simply true. Most people don’t even consider otherwise.
But what about when they do?
This brings us back to the viral video posted on the Mormon Channel. Elaborating the earlier discussion, I’m arguing here that Heather’s video is functioning as a proxy “galvanizing” moment for tens of thousands of Latter-day Saints: one that effectively draws upon Mormon faith in God to help convert viewers to another narrative of healing.
Rather than merely watching it, Heather’s experience enacts a similar transformation for the video’s vast, word-wide audience, leading potentially hundreds of thousands of people toward a wide embrace of this same treatment path. It’s hard to imagine a message that would be more effective in persuading Mormons to adopt this way of thinking (and, indeed, I couldn’t help thinking how happy executives at Eli Lilly, Glaxo-Smith Kline and others were when the video came out).
How many tens or hundreds of thousands other people have been moved to follow the same path by the Mormon Channel video and its associated campaign? Speaking of the video, one commentator wrote the following in her comments:
- “This…is so amazing. Touched my heart in every degree. God answers our prayers in mysterious ways- sometimes the ways we don’t want/or expect. I feel for her so much – recently I went to my Bishop and discussed my mental state with him and I am soon to be taking therapy and possibly needing antidepressants…. I’m still uneasy and nervous, but excited for my future.”
Maybe that’s all a good thing? And maybe it’s not.
I feel obligated to at least raise the concerns from what I have seen. I hope and pray we will take the long-term evidence more seriously in our evaluations of what to do next.
And to be clear, it’s not the mere acceptance of medical treatment that is the concern here. It’s the larger narrative of fundamental deficiency and life-long disorder I’m raising concerns with, accompanied by the de facto invitation toward life-long treatment. How many people with serious mental/emotional distress who are being shepherded in this direction have an awareness of the long-term risks of this path, or about other alternatives available?
Let me say this in another way: The especially vivid redemptive narrative embodied in Heather’s video has, I believe, a distinctive power to set people on an especially unique path involving a level of commitment and trust in psychiatric treatment that, or many, will undoubtedly turn into especially long-term use.
It’s this path of long-term use that we need to discuss more carefully. Indeed, based on all available evidence, this pathway does not end well. I’ve personally watched this devastating long-term pattern happen, over and over – with many people in my life and professional associations over the last 15 years since starting my dissertation. Since completing my own study, I have also spoken with hundreds of other people about their experiences – experiences consistent with all the long-term patterns identified in the research.
If this research is to be believed, then we’re making a significant mistake in how we’re approaching mental health. To say it directly, from the vantage point illustrated above, the approach we’re taking to mental health will expand the burden of mental health in the Church (as many believe it already continues to do in American society broadly).
Real-life consequences. As I’ve said repeatedly, these are not merely academic questions. For me (as for many others), the real-life consequences of these ideas in the lives of loved ones are now a daily reminder. Let me add a few final examples:
One woman was started on antidepressants as a young mother after being told she was overly negative. Ten years later, after dosages had increased and additional medications had ceased working, she was persuaded to start electroshock therapy every other week, to the point she was forgetting early memories of her children.
I have watched a male friend of mine on antidepressants for a decade now become the most miserable, unstable, out of control, desperate person I know.
So many of the stories people share about their experiences facing mental illness are intense: dark voices encouraging people to kill themselves, etc. What this analysis above suggests is that some of the persistent suicidal thoughts that plague folks may be, to some degree, connected to the chronic presence of the medication.
One more example: I worked with a girl who was facing some depression as a teenager. At some point, others encouraged her to try antidepressants, which had a positive initial effect – and was described by the family as a kind of redemption. After a few months, the dosage had to be increased. By the end of the second year, another medication was added.
I saw this woman a few years later at a community gathering. Her eyes looked glassy. She looked almost lost. She took her life almost 6 months later.
In the wake of such painful circumstances, we cannot expect family members to rewind and process all the factors that may have led to this tragedy. And undoubtedly, it’s rare for physicians involved to conclude anything other than “wow, bipolar depression is a painful condition.”
It’s time for that to change. And time to seriously reconsider how we are approaching mental health.
This is not me talking.
It is the statistics. The medical science.
And the thousands – and tens of thousands – of people who have “got help” just as they were encouraged ….and later on found themselves in a darker, more miserable place right now.
What should we be telling those people? And how many thousands/tens of thousands of people are currently on the same trajectory, sure to end up in the same place?
Please, please – for the welfare of these precious people – our brothers and sisters – let’s take seriously & talk seriously about this possibility. I’m not the only one weary at seeing amazing individuals enduring chronic suffering, especially when the best science tells us this is exactly what we can expect from this long-term approach to treatment.
Let’s talk about the evidence. Let’s talk about the stories. Let’s come up with a more sensible, reasonable approach – one that draws upon medications in the short-term as part of a package, then helps people to get off.
Let’s make sure no one is pressured to go on, because “this is the only way to make this go away.”
That’s simply not true.
Toward a more thoughtful, selective approach. While it will continue to be believed by many that if only people would get treatment they will be okay, as I’ve illustrated above, this overlooks a great deal of evidence. SO much depends on how that treatment is approached: Are people being told a medication may be a short-term part of a package of support? Or are they being told the drug is something their brain needs (forever) – and as long as they are compliant, they’ll be okay?
If so, we’re setting them up for heartache. Literally every research study I have seen on long-term effects confirms that. By comparison, if the medications are used selectively (for a time), and then people are supported (and encouraged) to taper off, all the evidence suggests their outcomes will be significantly better. (See Robert Whitaker discuss what this kind of selective medication approach might look like, drawing on an existing example from Lapland, Finland: A Selective Approach to Psychiatric Meds).
Imagine what it would be like if our entire missionary program adopted a similar selective approach. What kind of spike in healing and hope might result from that?
Instead of that kind of selective approach, I am concerned that the message many are hearing is more of a monolithic approach aligned with the NAMI perspective above. For instance, one former mission president told all the women of his ward that every teenager with mental health challenges needs to go out into the mission field compliant on a psychiatric prescription. And I recently learned of a missionary in a foreign country who after working with an LDS therapist and his mission president, everyone concluded it would be best to taper off a medication. But due to a policy that the missionary needed to stay on a medication he started for the rest of the mission, that was not allowed.
That would all make sense, of course, IF (a) the brains of these missionaries were fundamentally deficient and (b) the long-term evidence showed that ongoing medication use was crucial for lasting stability.
That’s simply not the case – not in relation to the brain, and not in relation to long-term outcomes. It’s not scientifically supported.
But that’s what we’re telling those desperately seeking our guidance and help.
For all these reasons, I write to warn we are moving in the wrong direction in our approach to depression and other serious mental/emotional challenges – by encouraging people along a path that doesn’t end well.
To summarize, once more: While antidepressants like Prozac can and do alleviate some depression, for some people – over some period of time, the long-term evidence is unmistakably clear: people who stay on antidepressants long-term – especially if that becomes their primary reliance – end up worse off.
Although this is a serious message, it is not an iconoclastic one. As Robert Whitaker frequently points out, even slight adjustments to treatment protocol might make a big difference. And I’m hopeful that many doctors who are presented with this data, could arrive at the same conviction.
Please know that there is an important place for doctors in this conversation – especially those using medications selectively and willing to respect patient choice (see Robert Whitaker’s own invitation and encouragement to doctors in the video below: Messages to GP’s & Psychiatrists).
To you doctors and other medical professionals: We need you to use your authority to do more than write a prescription. We need you to teach your patients and invite them to see the broader picture of what will be needed to find legitimately lasting healing.
And in many cases, that will include tapering off of psychiatric treatment.
Preserving the option of tapering. It’s important that both professionals and the general public knows how frequently it happens that patients describe “coming to life” again when they taper. That comes up over and over in my own interviews with people, and it’s something Robert Whitaker highlights from thousands of emails and calls he has received since his book came out (see below: Hopeful Tapering Experiences).
Despite this, many patients are fearful precisely because of things they are hearing from professionals – e.g., that they won’t be okay without it, that depression will come back, that their brain doesn’t function properly on its own, etc.
When medical professionals do supervise a taper, sometimes they inadvertently confirm some of these same fears. For instance, many doctors will cut the dosage in half – way, way too fast. (Dosage changes are one of the times when suicidal ideation can spike the most).
Please, please let’s make sure we’re teaching people truth, and not outdated theories.
And let’s honor people’s agency and intuition – making sure they are given option of tapering, and the proper support to do that successfully.
To hear from someone in authority that you need to stay on a medication long-term, is enough for many (obedient) Latter-day Saints to remove any other option from the table.
It’s time to help people find another way (at least those who want it – and, in many cases, desperately, want it).
To reiterate: Given the evidence reviewed above, if you do not let patients know about this option (or if you discourage it), there is strong reason to believe you are violating your oath to Do No Harm.
What I am not saying. To be clear, this is not an “anti-pharmaceutical” message? It’s an “anti-pharmaceutical-company-funding-our-mental-health-education” message.
Speaking now to those facing depression, I want to be exceedingly clear: If an antidepressant has helped you move towards healing, wonderful!! All I’m pointing out here is that antidepressants were never intended (or tested or proven) to be a long-term remedy. So, appreciate whatever help they have offer you now, but be sure to take advantage of this time to create an infrastructure for longer-term healing. And as part of that plan, consider the possibility of tapering off antidepressants as a part of your sustainable healing package.
When that time is right (and you and your loved ones are the best ones to know that, ideally in consultation with a doctor), you can begin the task of tapering off antidepressants. For people who have been taking antidepressants for years, this will not (and typically cannot) be a quick process, with a need for careful medical management and support. The pace and precise way of doing that needs to be carefully considered – and once again, hopefully with the supervision of a doctor.
Am I telling you to get off a medication? No, I do not have that authority. I am raising a question that others can consider for themselves. Although I have received a doctorate with a focus on this area of research, I cannot say whether or when it’s right for any given individual to consider the possibility of tapering off antidepressants. That depends on many factors only known to you. In other words, the information contained here does not constitute medical advice and should not be relied on as such. Furthermore, these are my own thoughts and do not represent any institution or person with whom I have collaborated.
If you only remember one thing from this paper, then here’s the most important takeaway: the FDA has approved antidepressants and other psychiatric meds for short-term use because that’s the clear limits of the short-term research.
But that’s not the way we are using these medications or talking about them.
Truly happy long-term? One of the more challenging things I raised in the Mama Dragons piece were questions about the long-term happiness of the youth adopting the Mama Dragon set of interpretations. I ask similar questions here about the long-term happiness of those adopting and living out a NAMI-aligned narrative of mental health.
I know you say that you are truly happy in your written stories and interviews.
But I have my doubts.
Because I have listened to you. Seen you. Interviewed you – and studied your stories for years.
I do not see long-term vibrancy. Or deep well-being.
I see you getting by…coping…functioning…managing courageously and bravely.
But not feeling truly well or at peace.
Am I wrong?
Yes, there is something noble about that. But is that all that is possible?
A path to get excited for. Imagine what it could mean for the thousands, tens of thousands and millions of people facing mental illness to hear a different story.
I know something about what that could mean. I’ve been sharing this message with people for ten years, and I have never – not once – seen individuals and families who are facing serious mental/emotional distress not feel immediately more hopeful. The two responses I most typically get are (1) wow – that feels refreshing! (2) I’ve never heard this before.
Contrast those sharing their stories after managing medically for years with this Mormon mother, Jocelyn Pedersen, who successfully tapered off the benzodiazepine she was on. The life, vibrancy she feels is unmistakable in her videos, including this one announcing her participation in one of the preeminent courses in the nation.(note: this is just a screenshot below – click through at the link to see the video).
Here’s the thing: There is so much reason to hope for those facing mental illness – so much more than people are currently hearing. There really is.
If so, is it time to share that with people?!
Aspirations without excitement. Based on conversations across 15 years, my estimate is that upwards of 90% of people have never heard these reasons above to believe in lasting healing. Most people have never been given any more aspiration than effectively coping and managing.
Instead of looking into some of the reasons these people aren’t getting better, these outcomes are rationalized as “just the way depression is” and the “best people can hope for (for now).”
Is it only in the resurrection that Jesus can heal those facing mental illness? Or is more possible now?
While still holding out hope for ultimate and final healing in the resurrection, perhaps Christians can hold out more hope for today as well.
In some cases, whether this happens may be a life or death issue, with the lack of any other way potentially devastating.
I was approached by woman after a depression workshop with tears in her eyes, telling me that her dear friend (a Mormon mother) had been facing some mental distress and started a course of psychiatric medication. Due to the sexual side-effects they were causing, however, she re-approached her psychiatrist asking if there was any other way of moving forward, considering the burden of these side-effects.
His response to her was jarring: “No, there isn’t. This is the condition you have, and it’s likely you will need to be on a medication like this the rest of your life.”
With that definitive answer, this mother went home, wrote a note to her children and husband, then went out and shot herself.
Am I blaming her suicide (to some degree) on what her doctor told her?
It’s very difficult not to…and hard to deny that his authoritative pronouncement did not deepen her despair.
Clearly, no one knows all the factors in any suicide. I’m arguing that her narrative itself shows that comment was a triggering factor.
If so, there’s no way the physician saw his comment as responsible. No doubt, it was “how terrible bipolar depression is.”
New year hopes for those facing mental illness. What I would love to see is a truly new year for people on this path – with fresh possibilities.
Imagine – just for a moment – a mental health approach that emphasized not trying to make symptoms go away as fast as possible, but which tried to explore and understand why the symptoms were there and what deeper patterns they might call for changing?
Imagine all the women facing depression, all the teenagers facing depression, all the men pretending to be okay…going on this kind of an exploration. What life changes would be prompted? What insights and discoveries provoked? What depth of healing would be sparked?
Now compare that, in your mind’s eye, with all these same people being told that “actually – this has nothing to do with anything you’re doing in your life, it’s really just a brain deficiency that – as long as we medically treat with the right medication – will lead to stabilization and healing. Imagine the kind of life trajectory those people are now on – in comparison to what they might be on?
Because this contrast feels so crucial, let’s reiterate it in a thought experiment with greater detail. Imagine, for a moment, taking 100 people facing significant mental/emotional distress (half adult / half youth – some men and some women).
Imagine taking those 100 and telling them only three things: (1) This likely something you will face throughout your life (2) This arises from a chemical deficiency in your brain (3) That’s okay, though, because we can give you something to correct that deficiency – something you may need to take for a while or for the rest of your life.
NOW – take a second hundred people reflecting the same demographic characteristics and the same level of distress, and tell them this: (1) While this may be difficult right now, there is every reason to believe that real, sustainable healing is possible for you (2) While your brain and body are definitely involved, we can do things to help them move in a better direction and heal (3) If it seems right to use medications, that can be for a temporary season and we can eventually taper off of them.
Now follow those groups out as they grapple forward with their own path of healing. And then answer for yourself: how do the two groups compare looking out long-term?
The reality is that this thought experiment is proceeding as we speak. Right now, most everyone – male and female, young and old, is being shepherded along pathway #1. An army of bright, sensitive, amazing people have been convinced that – rather than exploring the hundreds of ways they might adjust their lives, hearts and minds – that all they need to do is wait for the right medication to work on their deficient brain.
Honest questions. Does anyone actually feel good – enthusiastic about our current approach?
That’s my first sincere question: does anyone actually like how many young missionaries, mothers and priesthood leaders we’re putting on these meds (for years at a time?)
Second question: now that we’ve tried this approach for decades, aren’t we seeing the very evidence that these long-term studies document? Aren’t things continuing to worsen? If so, is it not time for a change?
It’s hard not to bring up the famous anonymous quote attempting to define “insanity:” “doing the same thing over and over again and expecting different results.”
In a 2015 talk, Robert Whitaker stated, “At some point, it becomes a social responsibility and a question to look at this evidence, then you all decide how meaningful is this? How convincing is it?”
I will admit, I’m tired of seeing bright, sensitive, amazing people led down a path so clearly contraindicated by the best available research.
I’m tired of a suffering that cannot be expected to end as long as such an unsustainable path is being pursued for millions.
It’s hard not to conclude based on all the long-term evidence that people will not find lasting healing as long as they are medicated long-term.
And that’s precisely where most people facing serious mental illness are!
And why? As noted above, in large part because of groups like NAMI and the millions of dollars of funding that put their education in the hands of American families …while other industry-independent curricula get largely ignored.
It’s absolutely crucial – life and death crucial – that we pursue a broader conversation about mental health in this country. You can hear below Robert Whitaker’s own thoughts about the kind of conversation we need to be having right now: The Public Mental Health Conversation We Need to Have
Pursuing a broader conversation. For those interested in hearing more about this broader approach to working with mental/emotional distress, check out this free online course available here – Mindweather 101: Creative ways to work with intense thoughts and emotions – a class drawing on insights from many professionals and researchers. As you will see in the class, the good news is that there are real answers that help people unsettle root contributors, unsettle vulnerability, set them out to a path of lasting healing (by the way, we say nothing about antidepressants – encouraging people to talk with their doctors. That was on purpose, so that these discussions could take place with physicians).
I close here with words Robert Whitaker sometimes shares at the end of his talks, about the opportunity and challenge ahead of us :
The Opportunity: “History and science are telling us that there is a natural capacity to recover from depression, and that even bipolar disorder runs an episodic course, with fairly good long-term outcomes.”
The Challenge: How can we help people in a way that “enhances that natural capacity to recovery?”
As our own contributions to helping invite more forward movement, our non-profit will be launching two projects in 2018:
1. Sustainable Healing Story Project. I’ve met many people over the years who have found lasting, sustainable healing from serious depression, bipolar disorder, panic disorder and schizophrenia. But guess what?
Very few people have heard their story. We will be gathering more of these stories, and finding different ways to share them, including interviewing people on video.
2. Tapering Project. One of my colleagues Laura Delano just launched a wonderful online initiative to provide support to those seeking to taper. After years of being on psychiatric treatment, Laura tapered off and has spent years gathering information about how to pursue a thoughtful wise, gradual, stepped, withdrawal plan: See The Withdrawal Project. If you are a provider interested in being involved in offering your services to help those tapering OR if you’re someone seeking support, I highly recommend her website.
Because there are still important questions about the tapering process, especially for those who have been on medications for many years, we will be inviting people who are willing to share their story and experiences of tapering to contact us for participation in an ongoing story gathering project. We would like to better understand more of people’s long-term experience – especially those who have interest or experience pursuing tapering after many years. Themes across stories will be shared publicly on our website. We welcome any and all questions and inquiries (here).
Dr. David Cohen, a colleague at UCLA, is currently completing a review of the best recommendations in the scientific literature on psychotropic discontinuation and withdrawal. As soon as this review is completed, we’ll also be posting it on our mental health website for individual families and professionals looking for additional guidance.
If you would be willing to help support one or both of these projects, please consider a donation to our non-profit (check out our friends at the Foundation for Excellence in Mental Health Care as well).
In closing, please, please – for the well-being of those many facing depression, anxiety and other conditions, three entreaties:
- Stop telling people that their long-term well-being depends on staying on meds the rest of their life. Let’s stop hinting to patients that getting on antidepressants is what God (or his prophets) want them to do – e.g., “it’s the right thing.” If individual people feel guided to start an antidepressant after consultation with a physician, great! But let’s also provide support to those who want to taper off.
- Let’s begin the process of divesting ourselves as a people from the NAMI story – particularly those messages that remove people’s hope in deep and lasting healing and/or convince them that their greatest hope lies in long-term treatment. We shouldn’t be sending members the world over to NAMI as a reliable, unbiased source. And we shouldn’t be promoting a glory story of long-term medical management, when so much research suggests we’re setting people up on a painful path.
- Let’s please provide those facing serious mental or emotional challenges with more substantial hope for even the possibility of real healing in their future. When it comes to lasting recovery, as one person reminded me, the difference between no hope and some hope is very large. Let’s promote more stories of those who have found truly sustainable healing and rethink the promotion of stories that invite deep and fundamental trust in psychiatric treatment as a central hinge-point in healing. If those leading these mental health initiatives still choose to share a story like Heather’s, consider adding stories like Jocelyn Pedersen’s above to provide some balance.
Phew! We’re done now….with two more lines. (:
Overall, let’s insist on a broader conversation about these difficult questions in mental health, being willing to allow tough questions like these to be faced and explored. The well-being of the most vulnerable among us calls for nothing less.
Jacob Hess is on the board of the National Coalition of Dialogue & Deliberation and is the author of 14 peer reviewed articles exploring contrasting narratives of mental health and sociopolitical issues. These include four articles exploring contrasting narratives of the brain’s role in mental disorder, recovery from mental disorder, “successful” treatment for mental disorders and the larger public mental health dialogue. Jacob has (co)authored three books: You’re Not as Crazy as I Thought, But You’re Still Wrong, Once Upon a Time…He Wasn’t Feeling It Anymore and A Third Space: Proposing Another Way Forward in the LGBT/Religious Conservative Impasse (Disagreement Practice, Treasonous Friendship & Trustworthy Rivalry in the Face of Irreconcilable Difference). His work with Phil Neisser at State University of New York has been featured on This American Life and was recently honored by Public Conversations Project. has also worked for years with Living Room Conversations and the Village Square. Jacob’s life work is dedicated to making space for thoughtful, good-hearted people to find understanding (and affection) while exploring together the deepest of disagreements.
Special thanks to Yvonne Jacobs for the thorough and fantastic editing help!
 Pratt, L.A., Brody, D.J. & Gu, Q. (2017). Antidepressant Use Among Persons Aged 12 and Over: United States, 2011–2014 NCHS Data Brief, No. 283.
 I want to make clear that am a happy member of the LDS Church and love my local and general leaders. This is intended to raise awareness about inadvertent consequences of a particular treatment approach, and not to criticize the LDS Church or its leaders, who I’m confident continue to grapple with the best path forward on this issue. This goes into much greater detail than other related writing in the past – some of what I have passed along and shared with those involved in the mental health initiatives of the LDS Church. Given how public and extensive the LDS mental health education has been, it felt important to raise these concerns publicly as well. It’s important to acknowledge that our approach to mental health in the LDS community is just a microcosm of the world. And that much of what I have to say could be said about any community anywhere.
 Horne, R. & Weinman, J. (1999). Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47(6):555-67. (p. 555).
 Benkert, O., Graf-Morgenstern, M., Hillert, A., Sandmann J., Ehmig S. C., Weissbecker, H., Kepplinger H. M. & Sobota, K (1997). Public opinion on psychotropic drugs: an analysis of the factors influencing acceptance or rejection. Journal of Nervous Mental Disorders, 185(3), 151-8. These concerns vary according to demographics, with younger people, women and ethnic minorities reported to be more hesitant. It is also worth noting that medication concerns vary according to certain individual characteristics. Based on a questionnaire survey among 895 adult patients attending 20 general practices in England, significantly more men (67.4%) than women (54%) believed antidepressants to be “addictive” (Churchhill et al., 2000). A recent telephone survey of 829 ethnically diverse patients meeting criteria for clinical depression in the prior year found that African Americans and Hispanics are both less likely than Caucasian individuals to embrace antidepressant medication (Cooper et al., 2003). Most recently, a large-scale Internet survey measuring treatment preference, stigma and attitudes toward depression across 78,753 persons with significant depressive symptoms confirmed the same pattern. Compared to whites, African Americans, Asians/Pacific Islanders and Hispanics were all more likely to prefer other things like counseling and prayer to medications; ethnic minorities were also less likely to believe in the efficacy of medication overall, and more likely hold beliefs that antidepressants were addictive (Givens et al., 2007). Younger patients also report slightly more resistance than older individuals (Griffith, 1990; Lorenc & Branthwaite, 1993). Moses and Kirk (2005) note a consistent ambivalence towards medication in youth, with large numbers embracing medication and other large numbers resisting it for its side effects. While resistance to medical treatment is fairly prevalent across demographics, it is thus disproportionally manifest in communities historically disenfranchised and oppressed: women, children and ethnic minorities.
 Streicker, S. K., Amdur, M., & Dincin, J. (1986). Educating patients about psychiatric medications: Failure to enhance compliance. Psychosocial Rehabilitation Journal, 9(4), 15-28.
 “Illness narratives tell us about the way cultural values and social relations shape how we perceive and monitor our bodies, label and categorize bodily symptoms, interpret complains in the particular context of our life situation” (p. xiii). Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.
 In their exploration of the depression experience of 43 women, Schreiber and Hartrick (2002) remark on the “profoundly influential” occasion of individuals first hearing about the biomedical explanation for depression. They describe how this encounter leads participants to question previous knowledge, and engage in “ongoing process of revision to accommodate new information,” ultimately “reformulating a new explanatory model,” which, at times “completely substitutes” for their previous understanding (pp. 96-97).
 It’s important to acknowledge something else clearly on display: This is a woman of remarkable faith, seeking answers from God and enduring such a painful trial.
 McAdams, D. P & Bowman, P.J. (2001). Narrating life’s turning points: Redemption and contamination. Chapter in D.P. McAdams (Ed); R. Josselson (Eds); et al. (2001). Turns in the road: Narrative studies of lives in transition. (pp. 3-34). McCubbin
 As reported in mainstream psychiatric textbooks, one-third of all unipolar patients are non-responders to antidepressants. Another third are partial responders. The final third of patients see their symptoms remit over the short term. Increasing attention has gone to the deteriorating third over recent years. For instance, this 2007 article: Cristina Cusin, et al., Early Symptomatic Worsening During Treatment With Fluoxetine in Major Depressive Disorder: Prevalence and Implications, Journal of Clinical Psychiatry, 68, 52-57.
 Psychiatrist Peter Breggin summarizes the process described in many neurochemistry and psychiatric textbooks: “The brain senses the abnormal increase of serotonin in the synapses and tries in several ways to reverse it. Starting with the first dose of Prozac or any other SSRI, the cells that produce serotonin begin to shut down. They stop releasing serotonin. The shutdown mechanism is similar to a safety shutoff on a pump that fills a pool. When the water in the pool exceeds the safe or required depth, the rising water sends a signal to the pump to shut down. Similarly, the rising level of serotonin signals neurons to stop releasing any more of the neurotransmitter into the synapse…In addition to shutting down the output of serotonin, the brain also compensates by becoming less sensitive to the effects of serotonin….The result of this well-known defense mechanism is called subsensitivity or downregulation” (The Anti-Depressant Fact Book, 2001, Perseus Publishing). For illustrative scientific references, see:
- Montigny, C. de, I. Chaput, and P. Blier. “Modification of Serotonergic Neuron Properties by Long-term Treatment with Serotonin Reuptake Blockers.” Journal of Clinical Psychiatry 51, supp. B (December 1990): 12.
- Wong, D., L. Reid, F. Bymaster, and P. Threlkeid. “Chronic Effects of Fluoxetine, a Selective Inhibitor of Serotonin Uptake, on Neurotransmitter Receptors, “Journal of Neural Transmission 64 (1985): 25-269.
- Wamsley, J.K., W.F. Byerley, R.T. McCabe, E.J. McConnell, T.M. Dawson, & B.I. Grosser. “Receptor Alterations Associated with Serotonergic Agents: An Autographic Analysis.” Journal of Clinical Psychiatry 48, no. 3 (supp, 1987): 19-85.
 This may be especially true in light of the vivid experiences people sometimes have initially. Speaking of one man’s experience, David notes, “No doubt Mike’s later disappointments with a wide array of drugs were deepened by their contrast with this early success.” [David Karp (2006). Is it me or my meds? Living with antidepressants. Cambridge, MA: Harvard University Press. pp. 45, 82].
 Marcus, G. (2004). The birth of the mind. New York: Perseus. pp. 45, 148; see also: Schwartz, J. M. & Begley, S. (2002). The mind and the brain: Neuroplasticity and the power of mental force. New York: Harper.
 Osterhout, L, Poliakovb, A., Inouea, K., McLaughlina, J., Valentinea, G., Pitkanena, I., Frenck-Mestred, C., & Hirschensohnc, J. (2008). Second-language learning and changes in the brain. Journal of Neurolinguistics, 21, 6, 509–521.
 Goldapple, K., Segal, Z., Garson, C., Lau, M., Bieling, P., Kennedy, S., & Mayberg, H. (2004). Modulation of cortical-limbic pathways in major depression: Treatment specific effects of cognitive behavior therapy. Archives of General Psychiatry, 61, 34–41.
 Garland, E.L, & Howard, M.O. (2009). Neuroplasticity, psychosocial genomics, and the biopsychosocial paradigm in the 21st century. Health and Social Work, 34(3), 191–199.
 Among other things, this suggests that mental disorder could be likened to other diseases that can eventually go away over time, given the right support and treatment. Published accounts of former patients illustrate this hopeful view of long-term recovery (e.g., Deegan 1988; Fisher, 2006), including that of Dr. Marsha Linehan, the creator of Dialectical Behavioral Therapy (DBT), who recently made public her own account of recovery from psychosis (Carey, 2011).
 Schwartz, J.M. & Begley, S. (2002). The mind and the brain: Neuroplasticity and the power of mental force. New York: Harper, pp. 128, 130, 366.
 Connelly, M. (2010, June 6). More Americans sense a downside to an online existence. New York Times News Service
 Federoff, N. & Botstein, D. (1992). The dynamic genome: Barbara McClintock’s ideas in the century of genetics. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press. See also: Handel, A. E., Ebers, G. C., & Ramagopala, S. V. (2010). Epigenetics: molecular mechanisms and implications for disease. Trends in Molecular Medicine 16(1), 7-16.
 Siegle, G.J. (1999). A neural network model of attention biases in depression. Progress in Brain Research, 121, 407–432.
Ottowitz, W.E., Tondo, L., Dougherty, D.D. & Savage, C.R. (2002). The neural network basis for abnormalities of attention and executive function in major depressive disorder: Implications for application of the medical disease model to psychiatric disorders. Harvard Review of Psychiatry, 10, 2, 86–99.
 Stein, D.J., & Ludik, J. (Eds.). (1998). Neural networks and psychopathology: Connectionist models in practice and research. Cambridge, uk: Cambridge University Press.
Hariri, A.R., Bookheimer, S.Y. & Mazziotta, J.C. (2000). Modulating emotional responses: Effects of a neocortical network on the limbic system. Motivation, Emotion, Feeding, Drinking, 11(1), 43–48.
 Ludik, J. & Stein, D.J. (1998). Neural-network modeling of cognitive disinhibition and neurotransmitter dysfunction in obsessive-compulsive disorder. In D.J. Stein & J. Ludik (Eds.). Neural networks and psychopathology: Connectionist models in practice and research (pp. 231–247). Cambridge, uk: Cambridge University Press.
 Berger, A. & Posner, M.I. (2000). Pathologies of brain attentional networks. Neuroscience and Biobehavioral Reviews, 24(1), 3–5.
Posnera, M.I., Sheesea, B.E., Odludaşa, Y., & Tangb, Y. (2006). Analyzing and shaping human attentional networks. Special issue: Brain and attention. Neural Networks, 19(9), 1422–1429.
 Chen, E.Y.H. & Berrios, G.E. (1998). The nature of delusions: A hierarchical, neural network approach. In D.J. Stein & J. Ludik (Eds), Neural networks and psychopathology: Connectionist models in practice and research (pp. 167–188). Cambridge, uk: Cambridge University Press.
Vinogradov, S., Poole, J.H., & Willis-Shore, J. (1998). ‘Produced by either God or Satan’: Neural network approaches to delusional thinking. In D.J. Stein & J. Ludik (Eds.). Neural networks and psychopathology: Connectionist models in practice and research (pp. 189–239), Cambridge, UK: Cambridge University Press.
 The manual goes on to acknowledge that “Physical and mental ‘workouts’ are proposed to rejuvenate fatigued brain cells, and even create new ones” while adding in the very same sentence “preliminary animal research suggests that antidepressants and lithium may actually spur development of new cells, and increase neuronal connections in the brain.” In other words: Brain changeability is controversial – but new evidence suggests medication can help it happen! Hmmmm…
 Dr. Ioannidis goes on to point out, however, a number of things:
- “While only half of these trials had formally significant effectiveness, published reports almost ubiquitously claimed significant results.”
- “’Negative’ trials were either left unpublished or were distorted to present ‘positive’ results.”
- “The average benefit of these drugs based on the FDA data was of small magnitude, while the published literature suggested larger benefits.”
With Dr. Jeff Lacasse at Florida State, I surveyed a number of similar patterns in these same studies, ranging from: inadequate blinding and/or use of inactive placebo (Antonuccio, Burns, & Danton, 2002), to the selective reporting of endpoints (Jureidini, McHenry, & Mansfield, 2008), selective publication (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008), and “ghost authorship” of peer-reviewed publications by companies and their subcontractors (Lacasse & Leo, 2010; Sismondo, 2009).
Dr. Ioannidis goes on to conclude, “These data suggest that antidepressants may be less effective than their wide marketing suggests. Short-term benefits are small and long-term balance of benefits and harms is understudied.” He goes on to detail throughout his paper “how the use of many small randomized trials with clinically non-relevant outcomes, improper interpretation of statistical significance, manipulated study design, biased selection of study populations, short follow-up, and selective and distorted reporting of results has built and nourished a seemingly evidence-based [story of] antidepressant effectiveness.”
 Ioannidis JP. “Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials?” Philosophy, Ethics, and Humanities in Medicine 2008 May 27;3:14.
 Kaplan BJ, Giesbrecht G, Shannon S, McLeod K. “Evaluating treatments in health care: the instability of a one-legged stool.”
BMC Medical Research Methodology 2011 May 11;11:65.
 See also: Slife, B. D., & Gantt, E. (1999). Methodological pluralism: A framework for psychotherapy research. Journal of Clinical Psychology, 55(12), 1–13.
 [OR = 4.05, 95% CI; 2.98, 5.51]. See Lexchin, J., Bero, L. A., Djulbegovic, B., & Clark, O. (2003). Pharmaceutical industry sponsorship and research outcome and quality: A systematic review. BMJ, 326, 1167–1176.
 We’re finishing a review of all the published “best practice standards” for depression, evaluating the different criteria of valid evidence, scope of what is reviewed (and not) and the funding sources for the work.
 NAMI’s not alone in this kind of advocacy and funding model. According to their own self-disclosures, other major mental health education organizations, including Mental Health America, Depression & Bipolar Support Alliances, American Foundation for Suicide Prevention & CHADD also receive a majority of their support from pharmaceutical companies (see here for more). And WEB-MD, among the most visited health websites online, is a product of Eli-Lilly (the maker of Prozac) (see here and here).
 Especially if we’re not aware it’s even happening! This is not about vilifying companies – but instead, drawing sensible firewalls that protect education from the natural conflict of interests that arise. As I argued with Dr. Lacasse in 2011, there’s a crucial need to be “advancing industry-independent education. If the general public is to make treatment decisions that are fully informed of the entire scope of costs and benefits, they deserve a picture independent of those standing to profit from those treatments.”
 Pages 40-42 in Valley of Sorrow.
 His 2005 article represents talking points almost indistinguishable from NAMI’s (Alexander B. Morrison, “Myths about Mental Illness,” Ensign, Oct. 2005, 31–35). During my dissertation, I reached out to Elder Morrison to be able to ask him about the message he was sharing with Church members. I explained how I was interviewing people about their in-depth experience of depression – and told him that his book had been influential. I asked Elder Morrison about his book’s emphasis on the reality of a “chemical imbalance” in the brain – letting him know about new evidence that had led many neuroscientists to reject that theory. He humbly acknowledged there was a lot we did not know.
 For instance:
- “Your spouse will probably require medical treatment, psychological counseling, or a combination of the two…Several types of antidepressant medications have proven helpful and can be obtained through medical consultation. These forms of medication do not typically produce dependencies and can be life-saving drugs to some people.” Why Is My Wife (Or Husband) Depressed? (1990 Ensign) David G. Weight
- “New medications have been developed in the past 10 years that treat a variety of symptoms, with fewer side effects than older medications.” Easing the Burdens of Mental Illness (2001 Ensign) Dawn and Jay Fox.
 “During the past 40 years numerous medications have been developed by the multinational pharmaceutical industry. These products have proven of inestimable worth to millions. They are not perfect, nor do they work effectively in every instance—far from it, unfortunately. But we are getting closer to the day when physicians will have available effective drugs which are specific in correcting the biochemical lesions concerned, without the side effects which too often limit the effectiveness of medications today. I have no doubt that such developments, which we are already beginning to see, will result in striking advances in the treatment of mental illness over the next decade.”
 Indeed, NAMI articles are highlighted 8 times across the LDS mental health site (more than any other listed organization) – with Alexander Morrison’s “Myths of Mental Illness” article cited multiple times as well. Themes common in NAMI education show up frequently in the interviews and Ensign articles shared on the site.
 I can’t help but say what an irresponsible and damaging thing this is to tell someone (not to mention a conviction without scientific or gospel foundation).
 Of significance to this review, this woman acknowledges she hasn’t found lasting healing from depression, even following what appears to be 20 years of medical treatment: “It has been more than 20 years since that first major episode with depression. I continue to battle mental illness. It is a daily struggle, helped by medication, good nutrition, exercise, recognizing and avoiding triggers, and seeking therapy when needed.”
 For instance, in this Ensign article referenced on the site: “With the medicine the doctor prescribed, Scott improved so significantly that his strange behavior disappeared.” The author acknowledges, “The road since then has not been easy for Scott or his family…For a while, Scott wondered every day if this would be the day he would take his life.” For years, Scott refused to believe that he needed the medicine, and he had periodic ‘breaks’ that resulted in hospitalization. But today, at thirty-five, Scott has a wife and beautiful baby daughter who give him a reason to stay on the medicine that keeps his illness under control, much as insulin controls diabetes. For several months now, with proper medication and supportive therapy, Scott has kept a full-time job and has led a relatively stable life. Scott is not “cured,” but with his symptoms under control, life looks brighter for him than it has for many years.” Mental Illness: Jan Underwood Pinborough, February 1989, Ensign
 She goes on to talk about “other blessings”: “at times when I needed it most I felt the Spirit of the Holy Ghost. Small answers came, enough to get me through each day.” She later adds, “through it all I have felt my Heavenly Father’s Spirit, his guidance, his love. Despite periods of despair and darkness, he has blessed me with the courage and light necessary to continue on. “ P. 40 Valley of Sorrow
 National Alliance for the Mentally Ill, NAMI (2011a). The Mind of America Foundation. Retrieved July 20, 2011 from: http://www.nami.org/Template.cfm?section=Mind_of_America_Foundation.
 National Alliance for the Mentally Ill, NAMI (2011b). What is a serious mental illness? Retrieved July 20, 2011 from: http://www.nami.org/ What is Mental Illness: Mental Illness Facts) Pamphlet: An Illness Like Any Other
 Vidler, H.C. (2005). Women making decisions about self-care and recovering from depression. Women’s Studies International Forum, 28, 289–303 (p. 296).
 Bilic, B., & Georgaca, E. (2007). Representations of “mental illness” in Serbian newspapers: A critical discourse analysis. Qualitative Research in Psychology, 4(1–2), 167–186. [p. 167].
 Brett J. Deacon and Grayson L. Baird (2009). The Chemical Imbalance Explanation of Depression: Reducing Blame at What Cost? Journal of Social and Clinical Psychology: Vol. 28, No. 4, pp. 415-435.
 Illustrating this unique stance on personal control, one woman said the “best change in my attitude was that I couldn’t help that this happened,” adding “but I can control it now, you know. I can take control of it”—going on to detail her careful management of the depression through medical means (5). Another individual said, “I’m responsible every single day for doing this mental inventory of ‘where am I?’ and when I notice the warning signs it’s my responsibility to do whatever it is I need to do. Whether I need to get in and see the doctor, get my medication adjusted, make an appointment, etc.” (13). Treatment compliance may, thus, become the primary thrust of personal control and effort—with a lack of compliance being the central issue.
 Richard Ferre, A mission to heal: Recovering from the trauma of early return: “If ye have desires to serve god…” Sunstone Magazine, p. 55, May 2003,
 Richard Ferre, A mission to heal: Recovering from the trauma of early return: “If ye have desires to serve god…” Sunstone Magazine, p. 54, May 2003,
 And this may perhaps even be limiting what God is able to do to help. In other words, the actions they may be taking could be preventing His full healing. Although that may be a controversial statement to orthodox Christians (who see God as being able to do anything He wants), it’s well accepted within Mormonism, as Truman Madsen once said, that “God is not all-powerful” (in the sense of doing anything He wants like, like Zeus). In order to be God, He must follow law, including the laws of the body and mind. To this view, the dominant approach to healing violates basic law in how the mind and body work – aka Mark Williams’ quote “the mind does not like to be forced – and if we try, we might like what comes of it.”
This is GOOD news, by the way, for the many people who have desperately begged God for relief, without finding any sustainable answers. Rather than just assuming God is saying no, or the illness is incurable, suddenly an entire new field of possibilities opens up: consideration of other healing approaches that best help the body and mind heal, while opening us to God’s power. (I respect that, for many people, even chronic use of medications might be what they see as the answer; for reasons outlined above, I believe we must keep looking).
 Mark Williams and colleagues, The Mindful Way Through Depression, 2007, p. 109
 Robert Whitaker has shared this story in multiple presentations over recent years.
 At least when it comes to public debates over gay marriage and sexuality, we know there are meaningful disagreements happening. More often in mental health, it is taken for granted that widespread agreement can be trusted as reliable and scientific.
 This comes from an analysis by Elizabeth Kantor at Harvard University of a survey of nearly 40,000 adults, from 1999 to 2012. She found that the percentage of Americans on antidepressants had doubled over this period.
 That is, perhaps, what the makers of the video hoped, no doubt sincerely: if only we could convince people to accept treatment and humble themselves, there would be less suffering. That is a sincere belief – and has become the widespread, dominant belief among mental health practitioners, doctors and educators.
 After witnessing this for a decade now, it feels like an ongoing, predictable-but-hidden train-wreck of enormous proportions – and one that we have (sincerely, with the best-of-intentions) invited people to get upon, thinking it will take us to the right place. Once people are on that train, it can be very difficult to get off – with a kind of momentum of long-term treatment in the body and mind. But as long as people recognize the train they are on, and understand some of the risks of the destination ahead, they can make their own choice about whether to take the steps to be able to get off.
But it’s so very clear: we are not recognizing what is happening. Not at all.
And we are not giving people the option of stepping off the train. Not enough.
 But what if you cannot find a doctor willing to supervise you? This is especially common given how many doctors have been fully convinced of the long-term chronicity of depression. Despite that, there are doctors willing to work with people interested in tapering, and who will support individuals following their sense of what is best. It is ideal when professionals support individuals in families in following their intuition of what is right, rather than overriding that by strong counsel.
 Read all you can about the process to get informed. I will only provide this guideline written by a doctor I trust at Harvard Medical School along with this new resource from a colleague I respect who has spent years gathering information about how to pursue a thoughtful wise, gradual, stepped, withdrawal plan: See The Withdrawal Project.
 On a profound level, this ultra common belief reflects a disturbing contradiction with the best scientific research out there. Aka, “this has nothing to do with anything you’re doing in your life (also scientifically false) it’s really just a brain deficiency (scientifically false)…that – as long as we medically treat with the right medication – will lead them to stabilization and healing (simply not true).”
 So sensitive that their minds and hearts feel in great depth the excruciating pain of our day…sometime, to a pathological degree.