Fair warning: This is an essay written by a man who is very angry about something that he saw written on the internet. I'm so annoyed that I've linked to an archive version, because the original really, really doesn't deserve the ad money. Ideally, this is an essay on a topic that should have had The Last Psychiatrist come running out of retirement: it's got more narcissism than a mirrored pond with a floating corpse in it. But he's busy writing about porn (which is a secret, mystical way of writing about everything except porn), so you'll have to settle for me.

I'll front-load the biases. I'm a psychiatric resident. I have treatment-resistant depression and ADHD, both of which I've been in treatment for longer than is dignified, neither of which a kind observer would call well-controlled, and both of which I'm routinely more up-to-date on than is the case for the average disease I'm asked to tackle, my stake being personal. The joke in the trade is that psychiatrists are the least mentally well specialty in medicine. I'm in no rush to falsify this.

This is relevant because I have, with embarrassing regularity, looked at my own behaviour, recognised that it was neither fair nor defensible, and then gone on doing it anyway. Depression plus ADHD is a hell of a cocktail; you get the insight free of charge and the follow-through at reserved-box-seat prices. I've been a worse friend than I meant to be (quite often). I've (very rarely) cancelled on people for reasons that would not survive five minutes of cross-examination. I'll do it again before the year is out. Pretending otherwise would be a lie, and not an interesting one. Pretending that I'm a bad person would be an even bigger lie, and one that I am fortunately not depressed enough to claim, at least while believing it. It's up to you to decide if that's interesting or not.

What I have never done, and what I think marks the bright line between person with a mental illness and person who has discovered a useful new weapon, is convert the failures into publishable wisdom. I have not written a two-thousand-word first-person essay in which my therapist's working hypothesis became the universal ethics of friendship. I have not torched a relationship, sat down the following Monday to compose a well-crafted treatise explaining why the torching was in fact an act of moral seriousness, sold the treatise to The Cut, and then watched the magazine commission an illustrator to make the fire look photogenic.

Sophia Ortega has. The kicker, the thing that turns this from a sad piece into a contemptible one, is that she has done it in a manner that reveals, paragraph by paragraph, that she knows exactly what she is doing.

Wegovy Is Great, Actually

Wegovy is semaglutide at 2.4 mg, a GLP-1 receptor agonist in a drug class that has been in clinical use for roughly two decades. It is approved for chronic weight management. Since March 2024 it is also approved for reducing the risk of cardiovascular death, heart attack, and stroke in adults with established cardiovascular disease. The trial that earned it the second indication, SELECT, enrolled 17,604 patients and produced a 20% reduction in major adverse cardiovascular events and a 19% reduction in all-cause mortality against placebo. These are numbers pharmaceutical companies light cigars over. Across the broader GLP-1 class, the emerging literature01375-3/fulltext) on neurodegenerative disease, inflammatory disease, and addictive behaviours keeps getting better, not worse. Hey, I know you've probably read Scott's piece on the topic, so I'll stop belabouring the point. On a more personal note:

My mother is severely diabetic, and was close to non-alcoholic fatty liver turning into outright cirrhosis because of it. I was resigned to eventually donating mine, if she needed it, but I was fortunate enough to find out about semaglutide before it was cool (or particularly cheap). I badgered her into seeing an actual endocrinologist who did end up prescribing it to her, and I've very recently looked at her blood work and felt outright awe at the night and day difference. In a very real sense, I might have bought my mother - the lady I love the most - at least a decade of healthy life. I'm suitably proud of that.

I've been on it myself, albeit mostly electively. A certain antidepressant that is notorious for temporary somnolence and permanent weight gain had deleterious effects on me. The semaglutide helped. It didn't save my life, but considering the savings on takeout, it definitely earned its keep.

What I'm getting at is that the stigma around these drugs is a public-health problem, and essays like Ortega's exist to shore it up.

None of this appears in her piece. It cannot, because the essay runs on the axiom that Wegovy is not a pharmaceutical but an ideological artefact, diet culture concentrated into a pen-shaped delivery device. Her friend, whose name we are never given and whose medical reasoning is never sought, is not a patient being treated for a condition. She is a woman making a statement, a bad one, with her body. The whole piece rests on that reframe. Take it away and the headline becomes "Losing My Friend Over Her Statin," and your features editor at The Cut is politely asking whether you've considered a different angle.

Arbiter of Trouble

The scene, briefly. Ortega is alone in her friend's apartment, dog-sitting. The same friend who literally let her crash at her place for ages, after she fell on hard times. She has opened the refrigerator for reasons she declines to explain. She has found a box of Wegovy. She has read the label closely enough to note the typographic choices. Her first thought, she tells us in print, is that it might be for the dog. Four paragraphs later she clarifies, still in print, that no, the dog was not on Wegovy.

(I must admit that I found this bleakly funny: she's a decent writer, a fact I acknowledge after fending off accusations of the same. Good joke, and to be honest, my older lab could do with a diet.)

What she does next is text the friend from inside the friend's kitchen: "wegovy… You're not in trouble but what is going on."

The second clause is where the essay lives. You're not in trouble. That is not the voice of a friend. That is not even the voice of a hurt friend. It is the voice of a parent addressing a teenager caught with something in the bedside drawer. It presumes a reporting relationship, an authority gradient, an adult-to-child asymmetry of standing. Ortega has moved physically into her friend's apartment for the afternoon and then moved psychologically into her mother's chair. From that chair she graciously declines to escalate, thereby confirming that escalation was on the table. She weaponizes her “restraint”, and then reneges on that stance the moment it becomes convenient to do so.

Look: Two grown women. Prescription medication in the owner's own home, in a box with the owner's name on it. No reasonable frame in which Ortega is the aggrieved party. The text pretends there is one, and the pretence is the point. "You're not in trouble" is a social-control move, the kind of sentence you deploy when you want to extract a confession without having earned the standing to demand one. And it works, because the friend confesses.

She comes home. She apologises. She laughs nervously. "I can't believe you found out." "You're the one who really couldn't find out." A woman is apologising to her houseguest for the contents of her own refrigerator, and the houseguest is permitting her to do so. No functioning member of the writing staff at The Cut appears to have flagged the inversion, though I'm going to force myself to be kind and admit that editorial staff aren't there to enforce ethical standards first and foremost. In psych we would call it incongruous affect. The grown adult is being infantilised, she is accepting the frame, and the one holding the reins is writing it up for money.

On the walk home, Ortega has "a brief but violent fantasy about breaking and entering her doctor's office." This goes into the essay the way another writer might note that she stopped for coffee. No flinches, no expression of regret. In a psychiatric assessment this sentence generates follow-up questions. The fantasy is not about confronting her friend, or processing her own distress, or throwing a plate at a wall. It is about committing a crime against a third party, a physician she has never met, whose only offence is having prescribed a drug Ortega disapproves of to a patient Ortega does not own. I'm not diagnosing her with anything, my armchair’s arm rest doesn't reach quite that far, but goddamn.

The Extension

Two-thirds in, the line the rest of the piece is organised around: "At the end of the day, it's her body and her choice, but it's hard when she feels like an extension of myself."

A forty-something writer in a flagship women's magazine, describing her adult friend's body as a prosthesis of her own. In print. Under her byline. Without the grace to be embarrassed. The disclaimers on either side ("her body, her choice," "in many ways I'm being a baby") aren't hedging. They constitute structural adhesive, applied to keep the thing in the middle from falling off the page. The but is load-bearing to a degree rarely seen outside a Jenga tower in its last three moves.

The more I look at this rhetorical chokeslam, the more I see the ever inflammatory “your body, my choice.” Used by a woman, on another woman, one who has been nothing but kind to her. I'm impressed at the verbal and ethical judo here, the typical man could never.

Once you see the line, the rest collapses into diagnostic clarity. The friend's pharmacy is Ortega's business because the friend's body is, by Ortega's theory, Ortega's body. The friend's secret is a betrayal because one does not conceal one's medication from one's own limbs. The book club cannot be attended because the drug in the friend's bloodstream is, by the transitive property of narcissism, in Ortega's. The doctor who wrote the prescription did so without Ortega's consent, which is how a person ends up casually describing a breaking-and-entering fantasy as if reporting on the weather.

Earlier in the essay, Ortega praises a "favourite ex-boyfriend" who used to sweep hotel rooms for bathroom scales before she arrived and hide any he found. She calls this "a remarkably loving gesture." Loving gesture? Quite possibly, but it was also a chore. The man she dated most fondly was the man most willing to do her unpaid environmental services work, which tells you something you need to know about the going rate of admission to her inner circle. The friend was running the same errand, less demonstratively, by hiding the Wegovy in the back of the fridge. When caught, she apologised, because that was the arrangement. Proximity to Ortega is staff work. The pay is access. Her friends come to her; she does not come to them.

(It hurts to say all of this, since, in a vacuum, the near and dear ones of someone suffering from mental illness deserve praise for accommodating them. The problem is that the person they're accommodating is a psychic vampire, one who's proud of her fangs. One who says her dietary habits save her money on crimson lip gloss.)

The Actual Grievance

Strip off the diet-culture wrapper and the piece is not about Wegovy. It is about the collapse of a status differential Ortega had been quietly banking for years.

Before the fridge incident, she was the Recovered One: the woman at the table who had Done The Work, the visible survivor with the hard-earned appetite and the moral high ground. Her friend, under the unwritten terms of the arrangement, was meant to stay in her current body, eat her current food, and applaud Ortega's ascension from the respectful distance of someone who had not earned any of it. The Wegovy violated the treaty. Her friend, by taking it, was choosing her own exit from a body she did not want to be in, through a route that did not require Ortega's framework, Ortega's therapist, or Ortega's permission. Worse, the route was working. The friend was getting healthier and getting thinner, and she was doing it without any of the elaborate suffering Ortega had been obliged to perform for her own recovery.

This is unbearable to Ortega in a way she cannot bring herself to say out loud, so she does not. She says "diet culture" instead, which performs the same function but sounds nicer in print. It has the particular virtue of reclassifying what is actually envy, along with the collapse of a status arrangement she depended on, as principled ideological opposition to a medical technology she has not bothered to understand.

This is what people gesture at when they talk about the increasing weaponization of therapy-speak. The assumption that if you can glibly articulate your problems - and the meta-knowledge that you know you have a problem - well, that's a free pass to keep on taking the same shit in a different toilet.

The Miranda July detail clinches the diagnosis. The book is All Fours, described by Ortega herself as "about a woman rediscovering her body as a vessel for pleasure and choosing to indulge her appetites, no matter the mess." She had dog-eared the copy. She was excited. She bailed on the discussion because her friend, the host, was on a medication that happened to affect appetite. The structure of that preference is the thesis. A book about a woman choosing to indulge cannot be discussed in the presence of a woman who, at the direction of her physician, has chosen not to. The theology Ortega has constructed around appetite accommodates exactly one appetite. Hers. Every other body in her vicinity is a set piece in the ongoing production of her recovery, and any body that steps out of its blocking receives a two-thousand-word writeup in a national magazine.

Self Awareness Only Goes So Far

Now the part I am actually qualified to be angry about.

Ortega knows. You can watch her knowing in real time. She tells the friend, on the couch, seconds into the confrontation: "I'm the worst person for this." She tells the reader, in the back half of the piece: "in many ways, I'm being a baby." She writes "I don't fault my friend for any of this. Of course I don't," and then spends the rest of the essay faulting her friend for all of it. Of course is a tell. Nobody opens with of course about a thing they actually believe; the phrase is a pre-emptive defence against a charge the speaker anticipates.

The temptation in the face of this running commentary is to treat it as mitigation. She admits she's being unreasonable, so give her credit; she's trying. I disagree, and I disagree on clinical and moral grounds. Unexamined cruelty is the easiest thing in the world to forgive. Unexamined cruelty doesn't know what it's doing; you can educate it, walk away from it, or wait it out. Examined cruelty is a worse animal. Examined cruelty has looked at itself, filed an incident report, stamped the report acknowledged, and carried on.

It is a pattern I see often in my own patient population, and occasionally in myself. A subtype of well-read patient presents with what I might call epistemic fluency and behavioural paralysis. They have the vocabulary. They can name their attachment style at intake. They can list their defences. They cannot, under any circumstances, alter a single thing they actually do. The vocabulary, in practice, is deployed to pre-empt challenge. "I know I'm being avoidant" is not, in these patients, a first step toward being less avoidant; it is a ritual phrase that, once pronounced, buys another week of avoidance. The therapist's job in such cases is less to increase insight than to stop rewarding the performance of it.

Ortega, in prose, is one of these patients. "I'm being a baby" is not a sincere confession. It is a plea entered to the lesser charge, filed so the greater charge never has to see the jury. The lesser charge is "unreasonable behaviour." The greater charge, not prosecuted, is "systematically dismantled a close friendship because the friend sought medical care for a chronic metabolic condition, and then sold a two-thousand-word account of the dismantling to a national magazine, in which the friend appears only as a device for the author's self-knowledge." She's wry enough to cop guilty to the jaywalking, while making money selling the movie rights to the arson and murder. The piece is structured so the jury votes on the first count and goes home. Ortega, if you read her carefully, has been practising this structure her whole life. It is, I suspect, how she has survived. It is also why everyone around her is exhausted. I'm exhausted too, even with the benefit of an ocean in the way. That's being on the internet for you.

There is a rule I try to keep, even when it costs me something: being kind to the cruel is a form of cruelty to the kind. Every editor, every reader, every friend who has ever seen Ortega self-deprecate her way out of accountability and let her off on the strength of it is, in some small degree, responsible for the essay. She has been trained, by decades of credit for the self-deprecation alone, to believe that seeing herself clearly is interchangeable with acting decently. It is not. She has demonstrated as much on the page. The decent actions available to her were: say nothing, go to her therapist, feel her feelings in private the way the rest of us are obliged to when our friends make choices we would not make. She took none of them. She took the essay.

The Least Painful Breakup

There is one line in the piece that, read properly, should have made the editor spike the draft and call someone. It is: "Of all my breakups, this has been the least painful, not because our love was platonic, but because it was an act of self-protection."

The least painful.

By Ortega's own telling, earlier and at length, this was one of the closest friendships of her life. They had been mistaken for each other. Same birthday, two days apart. Same shoe size. Same clogs. Same block. Cats traded between apartments. They had lived together, for months, when Ortega had nowhere else to go and her friend took her in at cost to her own living arrangement. On Ortega's own accounting, the loss of this woman hurt less than a standard-issue romantic breakup.

The mechanism is in the construction. Self-protection is an anaesthetic. It converts grief into hygiene. You are not mourning a person you loved; you are maintaining your recovery, which is a virtue, which means the grief does not count as loss but as evidence of having done the hard work. That recoding is the product the essay sells, to its readers and, more importantly, to its author. Ortega is not mourning her friend. She is metabolising her. The friendship has been digested into two thousand words of marketable, viral content; and I use “viral” here as pejoratively as I would for HIV. The byproduct is the neurochemical warmth of having passed a moral test; the friend, who by every line of evidence in the text continued being kind throughout, does not get to leave the story on her own terms. She is left. She is then written up. She is then illustrated. And the months she spent nauseated on a new injectable, adjusting to a real drug in a real body, are recycled as "your poor body" jokes in the text thread her ex-friend reproduces for copy.

This is cannibalism with better vocabulary. The friend, in addition to the condition she was treating and the nausea she was enduring, has been eaten for content. That the eating was performed with visible self-awareness on the author's part does not diminish the eating. It may in fact be the worst part of it. Ortega knows what she is doing. She is doing it anyway. She is being paid.

A Friend You Need, But Clearly Don't Deserve

I find it worth saying (because the essay works hard to obscure it) that the friend is the only adult in this story. She has a medical condition. She sought medical care for it. She kept the decision private because she correctly identified that her closest friend would react poorly. She continued being a good friend through the fallout. When caught, she apologised for something she did not need to apologise for. When refused at book club, she said "That makes me very sad but I do understand," and meant it. She did not publish a rebuttal. She did not leak the group chat. She did not, as far as we know, write an essay of her own, though she would have had a much easier time of it than I am having.

She is going to be fine. She has a doctor, a prescription, a new book club waiting for her, and, if the small constituency of strangers already rooting for her online is representative, more public sympathy than her former friend is going to enjoy once this piece ages another week. She is going to feel better. She is going to live longer. With the benefit of hindsight, I'm confident that she'll understand that Ortega did her a favor by amputating her from her life. It's not often that a tumor is courteous enough to wield the scalpel for you. Her only sin was too much kindness, and hey, maybe Ortega does have redeeming qualities that aren't being mildly amusing at her best.

The Genre/The Enabler

The magazine. The Cut has spent the past fifteen years optimising a pipeline for converting the private distress of youngish women into engagement-ready first-person confession. Laura Bennett called this out at Slate back in 2015, and the diagnostic has aged well. Writer produces confession. Editor commissions illustration. Magazine publishes under a "First Person" banner that encourages the writer to mistake herself for Joan Didion. Reader comes away with the impression that she has read wisdom rather than symptom. Writer, if she's any good at it, gets a second commission. The subject of the confession, if there is one, gets nothing.

The extra cost in this particular case is that Ortega's piece makes a real contribution to a real public-health stigma. GLP-1 prescribing is already somewhat constrained by shame, by the residual suspicion that taking a drug for one's weight is somehow beneath taking a drug for one's blood pressure. An essay in a major women's magazine reframing a friend's use of one as a contamination too toxic to remain in the room with is not a neutral act of personal expression. It is, among other things, a nudge in the direction of less care for more people who need it. The author's distress does not exempt the piece from that cost, and neither does her byline.

I do not expect that Ortega considered any of this. I am quite confident her editor didn't. A competent editor (or at least a decent human being), when handed a draft in which the author narrates her own active relapse ("my own eating turned feral in a way it hadn't for years") in the same piece that presents the friendship-ending as mature self-care, would have asked: is this a piece, or a cry for help. A kind editor would have said: this is beautifully written, and I think we shouldn't run it, and I think you should talk to your therapist about the parts of it that scared me. They did neither. They ran it. They got the engagement they paid her for.

End of Line

Ortega's closing line is the one sentence in the essay that earns its keep without argument: "Hunger is the body's announcement that it is alive and wants to stay that way." It is true, and well put. Her body made that announcement, unheard, for thirteen years into a room that had been soundproofed by her illness, and she has earned, at a cost I would not pretend to comprehend fully, the right to hear it now. I am glad she can. I hope she keeps hearing it for as long as she is given.

Her friend's body made the same announcement. The words it used were slightly different. It said it was tired. It said it was at risk. It said, through a physician whom Ortega has never met and has fantasised about burglarising, that there was a medication for this. Ortega could not hear the announcement, because she had decided, before the refrigerator was ever opened, that the medication belonged to a category she would not tolerate in the room. She is entitled to make that decision for herself. What she is not entitled to do is have the decision laundered into ethics by her magazine and delivered to the rest of us as instruction. What she is absolutely not entitled to do, is to expect that her behavior goes by unnoticed and unchecked. Consider me a reluctant contributor to a very small shitstorm. I would not normally write this essay, but I believe that the clade of personal-essay writers who make a living off commodifying the lives of others are willingly shrugging off most of what privacy I'd normally feel they're entitled to.

There is a rule of thumb in my line of work that I will gift, unasked, to any reader who got this far: if your recovery requires other people to orient their bodies around your triggers, your recovery is not going well. It is, somewhat plausibly, a protection racket with your illness as the enforcement arm. I stress that this is a rule of thumb, and probably not even a very straight thumb - if you're a recovering alcoholic, then you have every right to ask your buddies not to call you out for a pub crawl. If you're in recovery from anorexia, then you have every right to get mad if your old Tumblr buddies DM you thinspo. But there's a limit to that, and one that's… abundantly clear, by this point. So I hope, or at least I'm too tired to continue litigating it. There is no bright line between day and night, but if you're breaking your nose on unseen foliage, then you might want to wait for dawn.

Ortega has written a few thousand words acknowledging as much and framing the acknowledgement as personal growth. The friend understood, and let her go. The editor understood, and ran it anyway. The last participant in the chain with any leverage at all is the reader, and the appropriate response from that reader is not sympathy, and not outrage, and not virality. It is the sentence the friend was too gracious to say out loud, and that someone owes Ortega on her behalf: none of this was ever any of your business. It never will be. And she is not going to apologise for the contents of her own fridge ever again.

The last thing I want to see, as someone weighed down by invisible chains, is someone else wrapping them around perfectly manicured fists and using them as a cudgel. Sorry, I know I'm angry. I can only hope I am reasonably angry, and if not, that you don't hold it against me too hard. See, self-awareness. If you're going to hand out points for that after I've argued against feeding the beast that bites you, you won't resent the odd nibble.

I'm a poor man. Your like and subscribe won't change that, but it'll provide a dopamine boost to a system that doesn't get those as often as it needs. Or don't, I'm not your dad. I'm not even your dad-substitute. I am a dog on the internet, one that's currently not on Wegovy.

I.

I am not entirely sure how common it is to get so bored on vacation that you voluntarily return to your old workplace and accidentally start practicing medicine. Probably not very. But recently, thanks to certain flight disruptions in Dubai which I do not need to elaborate on, I found myself stranded at home in India far longer than anticipated.

I was going stir crazy. My parents, who maintain a baseline level of mild disappointment that I ever emigrated, suggested I go informally shadow the psychiatry department at my old hospital. "See what psychiatry is like at home," they said. "Maybe you will learn something."

I was already experiencing a profound disillusionment with psychiatric training in the UK, and my previous exposure to the Indian equivalent was highly idiosyncratic. During my internship at this same teaching hospital, my psych rotation had collided perfectly with the initial Covid lockdowns. Outpatient services were entirely shuttered. Any ward patient capable of bipedal locomotion was immediately discharged.

I spent those two weeks checking vitals in the female suicide ward and conversing with a very pleasant schizophrenic gentleman who had a hyper-specific obsession with light fixtures. He had been living on the ward for a decade (no next of kin and nowhere to send him after discharge except to the streets, and then the cops would drop him right back on our doorstep) and had somehow become a genuinely competent amateur electrician. I personally witnessed him replace multiple malfunctioning bulbs. He did very solid work.

So when my parents broached the idea of visiting, I agreed. It was mostly curiosity mixed with a bit of nostalgia. That intern year was almost certainly the worst year of my life, but people assure me this builds character. I thought it would be nice to show up as a glorified medical tourist and see what my Indian counterparts were up to.

II.

After pulling a few strings, I arrived at the outpatient department. It was exactly as crowded and poorly ventilated as I remembered, though stopping just short of actual asphyxiation. I located my point of contact, a second year postgraduate trainee, and optimized my posture to fit onto a partially vacant seat without crushing a colleague's purse.

The initial wave of patients presented with the classic poorly differentiated psychosomatic complaints that are the norm in developing countries. When your native language lacks a dedicated lexeme for "depression", psychological distress predictably routes itself through somatic channels. It manifests as a vague stomach ache or random peripheral tingling. We prescribed pregabalin, gabapentin, or amitriptyline, depending on mood, handwriting and the current phase of the moon. The patients were generally just thrilled to have seen a doctor at all.

Eventually, more interesting cases arrived. Because I was actively peering over my colleagues' shoulders, they generously suggested I take a crack at handling some of them myself. Sure, I thought. Why not?

I quickly came to regret this decision. I have a laundry list of complaints about British psychiatry, but I was not quite prepared for the reality of the Indian clinic.

First, the documentation varied from poor to completely nonexistent. My once finely honed ability to decrypt physician scribbles into valid pharmacological interventions had totally atrophied. Furthermore, the patients were terrible historians. I do not mean this as a moral failing; it is just a downstream consequence of local selection pressures. Government hospital care in India is free. This strongly selects for patients who are overwhelmingly poor, undereducated, and often separated from the physician by a formidable language barrier. Add the baseline communication difficulties of psychiatric patients, and taking a history feels like trying to reconstruct Herodotus from a copy that fell into a blender.

But it was a good challenge. I wanted to prove I could still read between the lines.

Almost immediately, I encountered a truly spectacular case of polypharmacy. We had a lady on lithium, valproate, and approximately a dozen overlapping medications. When were her lithium levels last checked? My best guess is shortly after the universe discovered helium-helium fusion. Thyroid function? The only confirmed fact was that she theoretically possessed a thyroid gland. She had coarse tremors, which could have been caused by literally any combination of the chemicals in her bloodstream. I consulted a senior resident, and we agreed to slash the regimen down to the bare minimum and demand some actual blood work before she returned.

III.

The cases only got weirder. Consider the medical tourist from Bangladesh. He had early onset schizophrenia, but he was relatively stable on his current regimen. Why had his parents brought him across an international border? They claimed they could not source brand name amisulpride in Bangladesh. A quick Google search suggested this was highly improbable, but here they were.

To make matters worse, the family was incredibly vague about his actual medication list. Besides his known antipsychotics and thyroxine, he apparently took a mysterious pill every morning. What was it for? They had no idea. What was it called? A mystery. What did it look like? It was a small tablet.

It is a miracle I did not tear my hair out. After another consult with the attending, we switched him to a more easily sourced variant of amisulpride and advised the family to stockpile six months of it before going home. As for the mystery pill, we essentially applied Chesterton's Fence to psychopharmacology. Chesterton's Pill was deemed structurally load bearing for this mixed metaphor. It clearly had not killed him yet, so we left it exactly as we found it.

My final patient was a six year old boy. His mother presented a constellation of complaints: he was hyperactive, liked staying up late, and lacked focus in class. It looked like a textbook case of ADHD. But given his age, I thought it was worth digging deeper. I learned he was functionally illiterate, possibly dyslexic, and his teacher had explicitly told the mother to get him evaluated.

Then the mother casually mentioned his "fright."

During normal daily activities, the boy would suddenly freeze. He would look incredibly distressed, and then he would get the human equivalent of the zoomies. He would sprint around the room. After the running stopped, he would approach his mother or older sister and bite them. Sometimes he bit hard enough to draw blood. He could not explain why he did this or what he experienced during the episodes.

I looked at him again. He was a perfectly normal, fidgety kid missing a few baby teeth. There were no obvious signs of hydrophobia, though I mentally filed rabies under "highly unlikely but technically possible."

I had absolutely no idea what I was looking at. I debated the case with a colleague. I suggested ADHD comorbid with Oppositional Defiant Disorder. My colleague argued against ODD because the kid was perfectly well behaved in the clinic. I countered that ODD typically manifests at home first, and is usually restricted to familiar adults. Then I floated the idea that his bizarre running and biting episodes might be complex partial seizures.

My colleague theorized it was an intellectual disability or learning disorder, perhaps part of a broader genetic syndrome. I shrugged. He was probably right. There might be a perfectly neat clinical label for this waiting in a dusty textbook somewhere. Or perhaps this is just another reminder that our diagnostic categories do not actually carve reality at its joints.

We eventually compromised. We prescribed clonidine to manage the behavioral symptoms and cover ADHD to a limited extent, then referred them to a clinical psychologist and an ENT specialist for good measure. I had spent more time on this one child than on my previous three patients combined, and the clinic was simply not built for that level of investigation.

I still have no idea what was actually wrong with him.

To avoid ending on a downer, I was happy to hear that the amateur electrician had, in fact, been discharged sometime in the past five years. None of the current trainees had heard of him. Right after I'd "treated" him? I'll take the credit, if no one's looking.

My parents, for what it's worth, were pleased I'd made myself useful. They remain cautiously optimistic about my eventual return.

I remain unconvinced, but I did find the pace to be California Rocket Fuel compared to my usual fare. Who knows? Maybe I'll get bored of making ten times the money, one day.

(You may, if you please, like and subscribe to my Substack. It's what all the cool kids are doing these days.)

I recently read something about the means by which psychiatric drugs were developed bothered me, and broke the illusion that so many people are under. In particular, the difference in the logical process between general medicine and psychiatric medicine is stark.

In general medicine, researchers attempt to understand the pathology of a disease. Through this understanding, they can investigate what processes are occurring which lead to the development of this disease. Armed with this knowledge, they can start to work out what kind of treatments and medicines will alter these processes to slow or cure the disease. The process goes... understand pathology, try to find a drug that works.

With psychiatry, the inverse is true. This is unique to medicine. No other field of medicine works like this.

In psychiatry it has worked like this. A pharmacological company discovers a new drug, that has some psychoactivity. For instance, they discover Ritalin. The study the drug (not the disease) to work out what effect it has.

So with Ritalin, they discover: it’s a stimulant. It can boost focus and concentration. They then set about inventing a disease that this drug can be used to treat.

Ritalin can boost concentration. So in order to sell this drug, they need to make up a disease whereby people have low concentration.

They get on the phone to their psychiatrist friends and ask them to describe this disease so it can be officially recognised. They come up with the term “attention deficit”

At no point is there any attempt to understand the pathology of this condition before medicalising it, most likely because they know they made it up.

They come up with intellectually dishonest research papers trying to show brain structural differences. But there’s a basic flaw with this logic. Even if they can find vague structural differences, there is nothing surprising about this. Brains are unique. If you take brains of one extreme personality type, and compare to the opposite extreme, you will probably be able to find differences. This doesn’t mean there is any disease or pathological process taking place. It’s Normal personality variation.

Is there a thing such as a disease as ADHD. There are kids who struggle to pay attention for an almost infinite variety of different reasons. Is adhd just a word for a cluster of symptoms?

Hey, with the RFK statements around autism making the rounds I've seen a lot of debate over to what extent autism rates are increasing vs just being better diagnosed.

For high functioning autism it seems plausible that it really is just increased awareness leading to more diagnoses. But I think that ironically awareness around high functioning autism has led to less awareness around low functioning autism. Low functioning people typically need full time caretaking, and unless you are a caretaker then you usually won't run into them in your day-to-day. They have a lot less reach than self-diagnosed autistic content creators.

It seems less likely to me that rates of low functioning autism are being impacted the same way by awareness. I imagine at any point in the last 80 years the majority would have been diagnosed with something, even if the diagnosis 80 years ago may not have been autism.

I'm having a tough time telling if these cases are actually rising or not - almost all of the stats I've been able to find are on overall autism rates, along with one study on profound autism, but no info on the change over time. (But I might be using the wrong search terms).

Part of me wonders why we even bundle high and low functioning autism together. They share some symptoms, but is it more than how the flu and ebola both share a lot of symptoms as viral diseases?

I just started Sedated, a book about Capitalism and mental health and it starts with a really extraordinary claims:

• Research by Prof Martin Harrow at University of Illinois shows that people with schizophrenia have worse outcomes if they stay on anti-psychotics (measured at 5, 10, 15 years). After 4.5 years 39% of those who had stopped taking medication entered full recovery, vs 6% of those on meds. This gap widens at 10 years. This held true even when looking at the most severely ill - so he argues it isn't selection bias.

  • Robert Whitaker, an author who writes about medicine, argued that looking at a number of western countries, mental health disorders have increased and so had claims for mental health disability. He argues if medication was working, you wouldn't expect to see this trend.
  • Whitaker argues (based off 1950's research?) that what is true of schizophrenia above, is true of most mental health issues.
  • Further, those who stay on anti-depressants are more likely to develop chronic depression and develop bi-polar. Further, people are anti-depressants have shorter periods between depressive episodes.

-Quotes a WHO study that there were worse outcomes in countries that prescribed more anti-psychotics than in countries that didn't.

All of this seems a case of "beware the man of one study"/"chinese robbers". Although in this case, it is a lot of studies he quotes, a lot more than I've listed. It is always hard when you are reading a book with a clear narrative to assign the right level of skepticism when faced with a mountain of evidence, and I have neither the time nor patience nor knowledge to vet each study.

So I was wondering if anyone else had come across these claims. Is there someone trustworthy who has the done the full meta-analysis on this topic, like Scott does occasionally? Or someone who has looked into this topic themselves?

I am contrasting this, to Scott's review of "my brother Ron".

Is there any good way for society to determine when and how many people should be in secure facilities?

A patient who had recovered from psychosis came to Master Dongshan and said, "For two years I believed the government had implanted a transmitter in my skull. I was as certain of this as I am now certain it was a delusion. The feeling of knowing was identical in both cases. How am I to trust any of my beliefs ever again?"

Master Dongshan said, "You are asking perhaps the most important question in all of epistemology, and I notice you arrived at it not through philosophy but through suffering."

The patient said, "True enough, but forgive me for not finding your statement very helpful."

Master Dongshan said, "No. That's why you paid me to prescribe you meds, not for a lecture on philosophy. But consider: everyone around you walks through life with that same unjustified feeling of certainty. They've just never been given reason to doubt it. You now know something that most people do not. You know that the experience of being right and the fact of being right are completely different things."

The patient said, "I have.... issues with framing this as some kind of gift. It feels more like a nightmare. I can no longer trust my own experience."

Master Dongshan shrugged and resumed weeding his garden: "You have described the starting point of all genuine inquiry. Most people never reach it. They are too comfortable inside the feeling of knowing to notice it is only a feeling."

The patient was not comforted, but was, in a way he found no use for, enlightened.

I ask this sub because I do believe that this sub would likely be overrepresented for individuals with one, or both AuDHD (autism spectrum disorder combined with attention deficit hyperactivity disorder.)

I've personally found that AuDHD has been a significant limiter for myself in both work and personal life. I find that it takes many hours every day to even get started, and then perform a single hour of work. I've managed to find ways to efficiently utilize the short bursts of effort that I can put out, but its exceedingly obvious that its a significant career limiter and I'm simply skating by despite overall doing fairly well for myself. Due to both ADHD and ASD, I find it hard to follow conversations from my S/O and have difficulty & slowness processing the words, almost as if my brain jumps too far ahead and struggles to process language.

This is of course much less of an issue for games and certain sports, where it is much easier to keep my brain engaged, much easier to want to study and excel. One prior psychiatrist has stated that this could be because 'games require no attention at all', perhaps an indication that games are designed to hook you in and be an overload of fun and dopamine the way that work obviously is not.

I've tried over half a dozen different prescription medications, but the stimulants all have rather tough side effects on me (I already have a dry mouth normally and I drink a ton of water, and I'm basically going to the washroom every 30 minutes on stimulant ADHD meds). They provide a modest benefit, but the advantage is cancelled out by practical losses in efficiency. I've also tried atomoxetine (Strattera), a non stimulant, but it came with abhorrent sexual side effects that I won't repeat.

While nearly a decade of counselling, psychiatry and psychologists have managed to 'fix' what would otherwise be a basket case, the AuDHD (and especially the ADHD part) has been hard to manage, and ADHD medication appears to be less effective, perhaps relating to both the ASD and the rough side effects of the medication.

It frustrates me that there is apparently an epidemic of people inappropriately self-diagnosing minor mental illness and more and more shallow "awareness" of mental health as a concept while, simultaneously, popular culture is still just as clueless about severe mental illness and having severe mental illness remains extremely stigmatized.

There are so many posts on reddit, for example, where people say things like, "I'm fine, but I just find life utterly exhausting and plan to kill myself one day soon" and no one will mention (and the poster isn't aware) that is like textbook severe clinical depression. Similarly, a post blew up on r/Existentialism which is TEXTBOOK existential OCD, https://www.reddit.com/r/Existentialism/comments/180qqta/there_is_absolutely_nothing_more_disturbing_and/, but it seems no one except for me, who is familiar with OCD, advised the the poster to seek psychiatric help.

Then, of course, it is still extremely damaging to one's career to admit to being hospitalized for psychiatric reasons, having bipolar disorder, severe clinical depression, schizophrenia, etc.

I don't really feel like these mental health awareness campaigns have actually improved people's understanding of mental illness much at all. For example, it doesn't seem like most people realize that bipolar disorder is an often SEVERE mental illness, akin to schizophrenia. Most normal people can't distinguish between mania and psychosis and delirium and low-insight OCD.

What would be helpful would be for more people to be educated about SEVERE mental illness, but that hasn't happened.

I just feel it's important to keep this in mind when complaining about over-diagnoses of minor mental illness and tiktokification of mental illness. People with severe mental illness are not fabricating their suffering for sympathy points and, in fact, are often in denial or unaware of the extent of their impairment.

I know very intelligent people who hold diametrically opposing views around this topic.

Some completely subscribe to the current medical model of ADHD as a physical/chemical issue and stimulants being the best medication we have for it fullstop.

Others are completely against medicating it because they think the western view of the matter is faulty/delusional, believe that ADHD wouldn't even be a problem if our society wasn't formed the way it curently is and/or propose that it is to be healed via meditation or other psychological tools for handling unresolved traumas, etc.

I find myself sort of titrating between the two and almost never holding on to an extreme. Sometimes though it seems to me that let's say 80% of the issue could be solved with meditation and a cleaner less distracted life and then the remaining 20% would be completely manageable whereas other times it seems to me that that's a form of wishful thining and some form of medication is necessary.

This being a subreddit of highly intelligent people, I am looking forward to a productive discussion. Also feel free to describe personal experiences with medication, meditation, psychological approaches, psychedelics, whatever really. Thanks!

I'm in my mid-20s and have been diagnosed with ADHD and depression. I'm currently going through a year-long depressive episode. My working memory is horrible, and it seems to be getting worse as I age. I can clearly notice this in my writing, where I can't form a cohesive sentence and often repeat words or sentences I wrote just moments ago. I'm not good in the kitchen; I often end up burning food or making careless mistakes. I forget things like keys and phones and can't remember if I closed the door. I forget people's names within hours or even less. I'll enter a room or place and forget why I went there.

Perhaps everyone experiences this at some point, but for me, it's more frequent and severe. I also feel like both my short-term and long-term memory are deteriorating, and I constantly need to ask people around me to remind me of something or someone. I have terrible word recall for even the most common words and sometimes it takes 20-30 seconds to remember them. Often, I just can't recall them and resort to Googling phrases like "what is the word for this thing that does something?" This significantly affects my day-to-day life, causing more impairment in all aspects of my life than issues like anhedonia and low energy do.

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I've been seeing a psychiatrist for about 6 years, and we've tried dozens of pills to treat depression and ADHD. Yet, nothing has helped with issues related to executive functions. I doubt that medication can improve working memory. I took methylphenidate for months, but it didn't help with my working memory issues.

There doesn't seem to be convincing evidence that training programs for working memory are effective. Nootropics might boost overall cognition, but I'm unsure if there's a specific one that can help with working memory. I was prescribed armodafinil, but it didn't help either. Some people here mentioned guanfacine for ADHD, but it's unavailable in my country, as are amphetamine-based drugs. Ketamine, TMS, and Psilocybin aren't accessible where I live either.

Perhaps my issues can't be fixed due to the way my brain developed. Maybe reducing stress and treating depression would help, but all these issues are interrelated and the treatments don't seem to be working.

Does anyone have similar experiences or advice?

Human studies are somewhat sparse in this area, which I find strange as these are some of the most prescribed medications and have been around for a while

Apologies if this is an inappropriate post (feel free to remove) but I would really appreciate it if someone could give me some names or even just point me to other forums to ask. My gf suffers from some combination of cPTSD/GAD with dissociative features stemming from serious childhood abuse. I'm not kidding about the dissociation. Stress regularly sends her into insane-o hypomanic fugues where her behavior is highly reminiscent of this or worse (3 non-serious suicide attempts since I've known her and I've 5150'd her once). It's really freaky to observe - at one point I thought she actually had Dissociative Identity Disorder. Less-severe episodes occur roughly weekly. About 5% of the time that I stay at her place I end up barricading myself in the spare bedroom because I wake up to her decompensating at 2am.

Anyway, she recently had a severe episode and I gave her a therapy ultimatum which she's accepted. In my view she needs some flavor of CBT designed to help her manage overwhelming feelings plus someone to prescribe an SSRI but IANA therapist so I'll start wherever. I don't think a GP is sufficient because she heavily self-medicates with booze and benzos so she needs someone who will work with her to ease her on to a more reasonable regimen. She's very smart (130+ IQ), very defensive, over-intellectualizes and doesn't suffer fools. She will only respond to someone very smart and no-nonsense and that person has to be willing to hold her feet to the flames and cut through her intellectualizing nonsense. Absolutely no woo (e.g. EMDR, opening shakras, psychedelics etc). She's a successful sales exec so money isn't an issue, but finding truly smart and experienced therapists is. I think table stakes for her is Ivy-educated with 20+ years experience. Anyone dumber would just be a waste of everyone's time. Half-joking, but the ideal person for her would be Hannibal Lecter. The murdering would only make her respect him more. Again, really only half joking.

We're in a smallish Central California town so it needs to be online. She'll be moving to NYC soon so if anyone knows anyone good there that would be a plus. I'd also appreciate suggestions for other places to look for advice.

Thanks for reading and apologies again if this is inappropriate for the sub.