OT? NYT: Sleep therapy seen as aid for treating depression

Psychiatrists, who are all medical doctors, make some of the very best sleep docs, in my opinion. NYC is blessed with some particularly knowledgeable and effective ones.

Few illnesses are either purely physical or purely mental. Mental health affects people physically, and physical health affects people mentally.

Ideally, medicine for the individual should involve an integrated team of several disciplines. Some on this board have found that a shrink who does sleep makes for a very valuable member of their personal team.

Mileages vary.

Well, Ive found that for my mood to be good I have to get a lot of sleep overnight. With proper pressures, minimal leak rates. Everything has to be close to perfect. If anything is off, I dont sleep well and then I dont feel well during the daytime no matter how many Zolofts I take that day.

The only thing I have found that can just kind of "overrun" my bad mood that Im having that day from poor sleep (say I had a high leak that prior night) is to go do some really heavy aerobic exercise that day. Swim a mile freestyle or go hike five miles. That has an effect on my mood for the remainder of the day and for the following day that elevates my mood some.

As far as shrinks treating a medical problem, like I said Ive used two and fired both of them. Both had tendencies to "somaticize" OSA complaints I was telling them. That pulmonary sleep specialists do not do to me. I tell a pulmonary sleep specialist my sleep is sh*tty and I get a new pressure, a new machine, a new sleep study. I dont get blown off or told to take a pill. Or that Im just "worrying about it."

Once these psychiatrists get fully trained, Im telling you, their thinking becomes kind of entrenched. Everything is "in your mind" and physical complaints are "somatic complaints" or "somaticizing." Which is EXTREMELY irritating and dangerous even. Ive long learned to keep my medical stuff separate from my psychiatrist who prescribes my SSRI and my klonopin.

psychiatrists in America (it might be different in certain countries overseas, I dont know) are concerned with: mood, thoughts, feelings, personality. They are not concerned with anything else. I learned that the hard way years ago. I wish it was otherwise, but that has been my experience, consistently over the years.

Eric

My take on Jim-Bob's points is that it is true that some in extreme mental anguish find that a sleepless night, or series of sleepless nights, will make them feel less of their pain the next day. (Sleep deprivation can dull pain and pleasure alike--it is hard to feel anything when you aren't mentally alert to life's sensations.) That is why some depressed and/or anxious patients self-treat with cycles of sleep deprivation in their attempts to find a way to function. It may seem to help short-term from the patient's point of view, but it does not, of course, equal a truely effective long-term solution.

For some in mental anguish, finding the source of the pain can help solve the problem. For others unable to get at the source, anything that seems to act as some sort of mental painkiller can feel to them like a good thing. Although actual sleep deprivation is not, to my knowledge, ever an accepted medical approach for anything, cycles of sleep deprivation followed by crashing for long periods, though a difficult way to live, is nevertheless how some people choose to live until better approaches to their problem are found and implemented. At the other extreme, other people in mental pain try to sleep as much as possible to spend less time awake and in pain. For them, restricting in-bed time in order to increase time in motion may be helpful, and I can see someone thinking of that as a form of sleep restriction--restricting bed time to what is reasonable.

I am not a medical professional, though. So those are only my impressions as a layman based on things I've seen and read.

SuddenlyWornOut45 wrote:Well, Ive found that for my mood to be good I have to get a lot of sleep overnight. With proper pressures, minimal leak rates. Everything has to be close to perfect. If anything is off, I dont sleep well and then I dont feel well during the daytime no matter how many Zolofts I take that day.

The only thing I have found that can just kind of "overrun" my bad mood that Im having that day from poor sleep (say I had a high leak that prior night) is to go do some really heavy aerobic exercise that day. Swim a mile freestyle or go hike five miles. That has an effect on my mood for the remainder of the day and for the following day that elevates my mood some.

As far as shrinks treating a medical problem, like I said Ive used two and fired both of them. Both had tendencies to "somaticize" OSA complaints I was telling them. That pulmonary sleep specialists do not do to me. I tell a pulmonary sleep specialist my sleep is sh*tty and I get a new pressure, a new machine, a new sleep study. I dont get blown off or told to take a pill. Or that Im just "worrying about it."

Once these psychiatrists get fully trained, Im telling you, their thinking becomes kind of entrenched. Everything is "in your mind" and physical complaints are "somatic complaints" or "somaticizing." Which is EXTREMELY irritating and dangerous even. Ive long learned to keep my medical stuff separate from my psychiatrist who prescribes my SSRI and my klonopin.

psychiatrists in America (it might be different in certain countries overseas, I dont know) are concerned with: mood, thoughts, feelings, personality. They are not concerned with anything else. I learned that the hard way years ago. I wish it was otherwise, but that has been my experience, consistently over the years.

Eric

In looking at effect size for psychiatric intervention - well - where is it? The research, when you can find it, looks suspicious and has little if anything positive to report anyway.

I have found that all of my issues have physiologic basis.

Getting rid of psychotropics and pursuing metabolic health has made me both feel and perform a lot better.

jnk wrote:Psychiatrists, who are all medical doctors, make some of the very best sleep docs, in my opinion. NYC is blessed with some particularly knowledgeable and effective ones.

Few illnesses are either purely physical or purely mental. Mental health affects people physically, and physical health affects people mentally.

Ideally, medicine for the individual should involve an integrated team of several disciplines. Some on this board have found that a shrink who does sleep makes for a very valuable member of their personal team.

Mileages vary.

JNK,

At the risk of getting this thread off target, even though psychiatrists are technically medical doctors, many of them don't act like it in my opinion. As a result, I totally agree with Eric about being very reluctant to see one for sleep with the exception of a neurpsychiatrist/sleep doctor out of my area who greatly helped two people I know. Unfortunately, he doesn't deal with apea issues because otherwise, i would suggest people on this board give him a shot if they needed someone and were in his area.

I do agree about people needing an integrated team of several disciplines. Ideally, all these folks would be under one practice but that is obviously not happening right now and won't for several years in my opinion.

49er

Point well taken, 49er.

A bad psych is likely to be a bad sleep doc. No doubt.

But I have heard a few psych-sleep docs speak who are amazingly knowledgeable on the importance of treating sleep first.

As one said in describing her practice: "We used to think in terms of bad sleep being the result of mental problems. We now more often think in terms of mental problems being the result of bad sleep."

Some of the most respected clinicians and researchers in sleep are also psychiatrists.

But like I said, a bad (or uneducated) psych is likely to be a bad (or uneducated) sleep doc too.

I appreciate your speaking up on it.

Yep, thats been my experiences as well. "many of them dont act like it" is dead on. Yeah, they have "MD" beside their name, but thats where it stops in the real world. In the real world, psychiatrists are concerned ONLY with thoughts, mood, perception, suicidal behavior, personality traits (sometimes), substance abuse problems (if any). Thats where the ball stops for these guys.

Some people, who have never dealt with a psychiatrist personally, do not truly get this. You have a medical problem? Dont go to a shrink for it...it WILL get blown off as a somatic complaint or as an obsession, compulsion, worrying, etc.

Eric

49er wrote:

jnk wrote:
.

even though psychiatrists are technically medical doctors, many of them don't act like it in my opinion. As a result, I totally agree with Eric about being very reluctant to see one for sleep

49er

I have never encountered a psychiatrist with that belief or attitude. See, you need to understand one very critical thing here. Sleep apnea and CPAP is not formally FDA approved for the treatment of depression or anxiety in those who are afflicted with sleep apnea. Even though EVERYBODY who is not living under a rock has it figured out that improving a serious sleep disorder like sleep apnea will improve mood during the daytime.

The problem is that only psychopharmacology like anti-depressants, lithium, ECT and talk pyschotherapy are formally "by the law" approved for treating mood and anxiety problems. psychiatrists who go outside that comfort zone of pill pushing and talk therapy and delve into CPAP therapy are putting themselves out liability wise if a patient ever commits suicide or even attempts suicide. It is all deadly serious and research is one thing, real world clinical practice is another thing.

And there is rivalry between sleep medicine and psychiatry, I have observed that personally. There is some dislike of one another there. shrinks know that some of their patient's mood and anxiety problems are being caused by untreated OSA and if the OSA gets treated, many of them will no longer need longterm medications and/or talk therapy. Hence the treated OSA patient will no longer need the services of mental health professionals. And sleep medicine knows there are a lot of mental patients who have untreated OSA but are not getting the referrals and CPAP support they should be getting. And all of this creates some dislike and rivalry.

My own shrink originally told me before being put on CPAP that it would "not help with my depression." He was wrong big time and when I told some sleep medicine specialists what he said, they gave me some really weird looks.

There is also some rivalry between the big pharma industry and the sleep medicine industry. Unless big pharma creates FDA approved pills for OSA, there will continue to be rivalry there. Big pharma has way more money and power than the still relatively small sleep medicine industry has.

jnk wrote:
As one said in describing her practice: "We used to think in terms of bad sleep being the result of mental problems. We now more often think in terms of mental problems being the result of bad sleep."

Also, if someone has both problems and chooses to use meds, there may be advantages to having one doc who understands both the sleep issues and the issues with specific meds.

As one site puts it:

some clinical dudes in cleveland wrote:"Treatment of co-existing psychiatric and sleep disorders requires a thorough evaluation by experts with knowledge in both sleep medicine and psychiatry. Medications to treat depression and anxiety must be chosen carefully, as some promote wakefulness while others cause drowsiness."--http://my.clevelandclinic.org/neurologi ... rders.aspx

That may not be as important for those going med-free, but still, just sayin'.

I dont consider insomnia a "sleep disorder." That is something that some sleep medicine specialists are attempting to both investigate and also to treat. And insomnia has traditionally, historically been the area of psychiatry. And that is one of the things I am talking about that is creating a rivalry between sleep medicine and psychiatry.

Insomnia I consider a symptom. Insomnia can be a symptom of either a psychiatric disorder such as clinical depression or untreated sleep apnea can cause insomnia. Additionally, stuff as simple as drinking too much caffeine can cause insomnia.

I consider "real sleep disorders" to be things like sleep disordered breathing, in all its forms. RLS and PLMD are real sleep disorders. I have read some sleep medicine specialists make the comment, "if it aint SBD, I dont even wanna see the patient." I hate to say this, but I agree with that attitude. Insomnia by itself, is small potatos compared to an untreated case of SBD or untreated RLS/PLMD.

Basically, psychiatry sees that as sleep medicine encroaching on their territory of "treating insomnia." Or even sleep medicine attempting to create a new "illness" out of the symptom of insomnia.

There might be some places where the psychiatry stuff is cordially or well coordinated with the sleep medicine stuff, but I have not seen any. In my experiences, its a rivalry issue...a turf war. It used to be psychiatry really only had one turf war enemy...psychotherapists (clinical psychologists). Psychiatrists are pill pushers and IMO, for good reason. Modern psychiatry believes serious mental disturbances are brain disorders and chemical imbalances. Hence the pill pusher mentality. Now though, psychiatry has two turf war enemies. The talk therapists and sleep medicine. Anything that screws with big pharma's money potentially (sleep medicine) is going to be blocked and tackled for as long as possible.

IMO, that is one of several reasons why so many OSA patients are untreated and/or non compliant. Longer term, treating OSA with CPAP is less profitable for the industries that manufacture medications.

jnk wrote:Also, if someone has both problems and chooses to use meds, there may be advantages to having one doc who understands both the sleep issues and the issues with specific meds.

As one site puts it:

some clinical dudes in cleveland wrote:"Treatment of co-existing psychiatric and sleep disorders requires a thorough evaluation by experts with knowledge in both sleep medicine and psychiatry. Medications to treat depression and anxiety must be chosen carefully, as some promote wakefulness while others cause drowsiness."--http://my.clevelandclinic.org/neurologi ... rders.aspx

That may not be as important for those going med-free, but still, just sayin'.

SuddenlyWornOut45 wrote:I dont consider insomnia a "sleep disorder." That is something that some sleep medicine specialists are attempting to both investigate and also to treat. And insomnia has traditionally, historically been the area of psychiatry. And that is one of the things I am talking about that is creating a rivalry between sleep medicine and psychiatry.

I beg to differ with that opinion. Insomnia has many roots and many of them are NOT psychiatric in their nature and do NOT need psychiatric solutions. Whether insomnia should be considered a "sleep disorder" is a good question.

Insomnia I consider a symptom. Insomnia can be a symptom of either a psychiatric disorder such as clinical depression or untreated sleep apnea can cause insomnia. Additionally, stuff as simple as drinking too much caffeine can cause insomnia.

We got to get some definitions agreed to here. Not sleeping for a night or two because of too much caffeine is not really insomnia---that's "a bad night of sleep". Most definitions of insomnia that I've seen talk about a persistent problem with getting to sleep, or staying asleep, or waking too early that occurs on at least 3 or 4 nights every week for at least two or three weeks AND the person experiencing it believes the sleep problem is a problem that is affecting the quality of their life in some way. (Typically, the person will complain, "I don't wake up rested and I have trouble getting or staying asleep at night.) In other words, the amorphous name "insomnia" is used to diagnose something that perceived to be a problem by the sufferer largely based on what the sufferer says rather than on any objective data. (In that sense it's kind of like nonspecific pain.)

The first thing that someone who tells a doctor that they're having a bit of trouble sleeping should be asked is: How long has it been going on?. Because most cases of "I can't seem to get to sleep" are indeed self limiting---if the person simply cuts down on the caffeine after lunch and tries to not worry too much about whatever it is that's causing the problem, the problem will usually resolve itself in a month or two. If it doesn't that's when the problem winds up with the amorphous name of "insomnia".

I also think that there are a whole lot of things that are far more common and may (or may not be) far more benign than either clinical depression or untreated sleep apnea that cause both short term and long term problems with insomnia. These include in no particular order:

• side effects of a whole bunch of medicines, including scads of OTC things we all use without thinking about them very seriously. Yet how many docs are willing to actually switch you off a med when you say, "I think this med is giving me insomnia"??
• untreated or undertreated pain, including chronic pain from common physical medical conditions, including TMJ problems, backache pain, arthritis, and chronic headache pain among other things. In serious, life threatening and painful illnesses, pain management is brought up explicitly. But as someone who suffered for 30+ years from daily chronic, but mild headaches without any referrals (because the pain was "mild") I can tell you that daily chronic headache pain has played a significant role in my on-again, off-again battle with insomnia that dates back to my child hood. (For those who insist on such things, the clear evidence of my OSA only dates back to my mid-40s and I'm now 55 and I was diagnosed with OSA at 52.)
• circadian rhythm disorders and shift worker sleep problems. Living on a schedule that your body does not want to live on will cause sleep problems.
• serious and substantial lifestyle transitions. Positive ones as well as negative ones. It's understandable how losing a job can lead to some pretty severe insomnia for a few months. A death in the family can also create sleep disruptions that last several weeks to months. But so can a wedding or starting a new job. Yeah, folks who want to label everything with a psychiatric label probably will call this one essentially psychiatric in its nature, but we all go through serious lifestyle transitions and insomnia is a common side effect of going through them. Usually this kind of insomnia is self-limiting---our sleep patterns start to return to normal after we adjust to the new lifestyle.
• life style choices that have subtly gotten out of control: It's one thing to have too much coffee once in awhile. It's another thing to not realize that your 6 cup a day habit might have something to do with the fact that you don't seem to sleep very soundly just because you've been drinking 6 caffeinated beverages since you were in college.
• plain old worry. A lot of us worry too much. Some of us worry so much that we really do have an anxiety disorder and need to take medication. But there's a whole lot of us that worry at levels that are at a sub-clinical level---not enough to warrant an anxiety disorder diagnosis, but enough to cause the insomnia monster to move into our bedroom on many a night when we're in active worry mode. Dr. Krakow talks a lot about the night time worries and how they feed the insomnia monster for a lot of people in Sound Sleep, Sound Mind. Learning how to create closure and how to stop worrying when you're prone to worrying, but not suffering from an anxiety disorder is important.
• a long history of going without enough sleep. It's a frequent problem for mothers with preschoolers and school aged kids. We're so used to functioning on so little sleep. As the mother, you're the first person up in the morning and the last person in bed at night. And (all to often) the parent who gets up in the middle of the night with the little ones. You get used to functioning on 4, 5, or 6 hours of fragmented sleep. And then when the kids finally are big enough where you ought to be able to sleep through the night? Your body just won't let go of that previous chaotic sleep schedule. And you still wake up in the middle of the night. Or earlier than everyone else. Or you find that you can't seem to fall asleep when you do go to bed early. Of course this problem is hardly confined to mothers in our culture. Just about anybody who finds themselves regularly burning the candle at both ends can be setting themselves up for long term sleep problems.

I consider "real sleep disorders" to be things like sleep disordered breathing, in all its forms. RLS and PLMD are real sleep disorders. I have read some sleep medicine specialists make the comment, "if it aint SBD, I dont even wanna see the patient." I hate to say this, but I agree with that attitude. Insomnia by itself, is small potatos compared to an untreated case of SBD or untreated RLS/PLMD.

Here is where I disagree with you significantly. The sad thing, in my humble opinion, is that we rely way too much on patient self reports to diagnose "insomnia" and the degree of insomnia. But there is real evidence from PSGs that insomniacs and noninsomniacs' brains do not function the same way when they are sleeping.

There have been numerous studies that have shown that when you put most insomniacs in a sleep lab, they have a much, much harder time accurately telling when they are asleep from when they are awake as compared to non-isomniacs. One study that I remember reading about had the investigators waking the subjects up at random and asking "Were you awake before I woke you?". Insomniacs typically answered, "Yes" regardless of the EEG evidence concerning the wake/sleep status before the wake was initiated; noninsomniacs typically answered the quesition correctly saying "No" when the EEG said they were asleep and "Yes" when they were awake. On questionaires following PSGs, insomniacs typically vastly OVER estimate the amount of Wake After Sleep (as compared to the EEG data) and UNDER estimate the actual sleep they get in the lab. Noninsomniacs are usually much more accurate in their estimates of sleep time.

So a real part of treating insomnia is (or should be) figuring out how to convince the insomniac that they actually have slept as much as they really have slept (and not as little as they think they have slept). It turns out that the real way most prescription sleeping pills work when it comes to treating intractable primary insomnia is essentially through that mechanism. The actually data gathered by PSGs and sleep logs shows that the actual amount of additional sleep time gained by taking 5-10mg of Ambien or the equivalent doses of Sonata or Lunesta is really very, very minor: As in, the average gain in amount of sleep per night with 5-10 mg of Ambien is something like a modest 30 minutes or so. And the average drop in latency to sleep is also very modest: With Ambien, users get to sleep maybe 10-15 minutes faster than without Ambien. And the EEG data from PSGs done with Ambien indicate that Ambien does NOTHING in terms of reducing WASO. But notably the reason so many people say that they sleep so much better on Ambien is that with Ambien, they are much less likely to remember any of those middle of the night wakes. And because they don't remember the wakes, they believe they're sleeping more soundly. And hence they believe their insomnia is better.

Basically, psychiatry sees that as sleep medicine encroaching on their territory of "treating insomnia." Or even sleep medicine attempting to create a new "illness" out of the symptom of insomnia.

Treating insomnia by prescribing sleeping pills that don't actually make you sleep any better, but do make you forget that you've woken up multiple times during the night is not really treating the problem is it? And that really is all that all of the currently commonly prescribed sleeping pills actually do.

Now for the heavier stuff---the antidepressants and so forth: If you're not clinically depressed, why should you take something that has the potential for so many serious side affects to fix a problem that you do not have in hopes that it may make you sleep better?

The sad fact is that big pharma and the docs have traditionally been content to simply push sleep pills on insomniacs. And as long as the side affects weren't too great, most insomniacs have been willing to take the drugs for years. And yet, they don't actually make you sleep any better in terms of total sleep time or latency to sleep. And some of them have had some pretty nasty side affects in terms of daytime hangovers and nighttime behaviors.

IMO, that is one of several reasons why so many OSA patients are untreated and/or non compliant. Longer term, treating OSA with CPAP is less profitable for the industries that manufacture medications.

In my opinion, the reason so many OSA patients are untreated or non compliant is that CPAP has a really bad reputation. Too many people out there hear the word "CPAP" and they think "I could NEVER EVER sleep with something attached to my face all night. I'd rather die first." And they continue to sleep badly. And sometimes they continue to plead that they just have insomnia to a doc who prescribes Ambien. And sometimes they die.

And when someone IS brave enough to get tested and brave enough to try CPAP, but then runs into serious problems with CPAP therapy making their sleep get much worse after starting therapy, too many sleep docs don't really help the patient do any real problem solving. Heck, they tend to blame the patient for the problems rather than help the patient understand what's going on and what might help and how long the nasty new sleep problems are likely to continue.

jnk wrote:Also, if someone has both problems and chooses to use meds, there may be advantages to having one doc who understands both the sleep issues and the issues with specific meds.

I am NOT clinically depressed. But I'm on BiPAP and I still have a great deal of difficulty sleeping with the BiPAP. As in if I'm not asleep within 15 minutes after putting the mask on, it will wake me up and I'll be miserable the rest of the night and toss and turn and never get soundly asleep. My newest sleep doc understands this. He's also the first sleep doc I've had that actually uses a CPAP. The other three docs? Not a one of them really had any idea of why I found using a PAP machine so hard to sleep with. The first one told me before I started: Don't worry about having problems sleeping; you'll feel fine in two weeks. Two weeks later, I was a walking zombie unable to function in the daytime due to excessive daytime sleepiness and unable to get to sleep until 3:00 or 4:00 AM because everytime I put the mask on my nose, it was like downing a double shot of expresso in terms of keying me up and jolting me wide awake because of all the physical stimuli coming from the machine.

My definition of "insomnia" is where a person goes to bed at a time of the day they should be going to sleep and lay there wide awake for a significant amount of time. Maybe hours. And have trouble falling asleep.

If you cant sleep all night and it lasts more than one night, thats not insomnia to me. Thats something else. Thats gone beyond insomnia. Definitely if you cant sleep or fall asleep for two nights in a row, thats not "insomnia" thats something else. Either a sleep disorder or some type of major psychiatric disorder.

In my twenties, before I had a breakdown that led to the diagnosis of major depression and treatment with anti-depressants, I used to have insomnia pretty regularly. I'd go to bed, lay there, could not fall asleep. I would not analyze it or worry about it. I just could not fall asleep on time. Instead of eight or nine hours of sleep, I might get six to seven hours of sleep. I found swimming on a Masters swim team three times a week greatly helped with insomnia. I also found back then that I would drink a few beers at night and that greatly helped my insomnia but now realize that was one of the worst ways to handle insomnia.

After I got put on CPAP in 2007, I learned that just the initial pressure from the machine blowing into my airway was one of THE BEST anti-insomnia treatments I had ever used.

I just dont look at insomnia as an illness unto itself. I think of insomnia as a symptom of something else. A symptom of sleep apnea, serious mood disorder, serious anxiety problems, drinking way too much caffeine during the day, not getting any exercise. I just dont think of insomnia as something that needs to be looked at like by itself, that is a disease or an illness. That is IMO, an ffed up way to think about insomnia.

Eric

jnk wrote:Temporary use of timing restrictions can be used as a tool for getting someone back on track with the timing and duration of his sleep. This would be done in the interests of ultimately improving both sleep and mood. Therefore, in my opinion, it would be a mischaracterization of such techniques to say that "making sleep worse can make some brain problems better."

It sounds like you are thinking about sleep restriction used as a tool in therapy for insomnia. I'm talking about sleep restriction as a therapy specifically for depression, as paradoxical as that sounds. Half a sec; I will dig out my Kryger, Roth, and Dement presently.

robysue wrote:

SuddenlyWornOut45 wrote:In fact, deterioration of sleep quality, insomnia and such is one of the main things psychiatrists and psychologists look for when evaluating someone for depression and also for severity of depression.

Sleep restriction or "sleep deprivation" is also well documented for causing psychosis. Stay awake long enough no matter who you are (mentally ill or not mentally ill) and you WILL hallucinate!!

Eric

Jim-Bob wrote:

jnk wrote:

But making sleep worse can make some brain problems better. At any rate, sleep restriction can be a therapeutic treatment for depression.

Sleep restriction as part of cognitive behavior therapy for insomnia is widely misunderstood: Sleep restriction therapy does NOT equal long term sleep deprivation. And I say this as someone who has done it under the supervision of a medical practioner. But I'll also say this: While it was an important part of winning my First War on Insomnia and it is becoming a critical tool in battling my on-going Second War on Insomnia, it is also NOT a therapy that is appropriate for everybody.

In short: Sleep restriction therapy may be useful when the problem is plain old insomina NOT complicated by depression AND the insomnia problem consists primarily of some combination of bedtime insomnia and too many disruptive lengthy night time wakes. In other words, sleep restriction therapy is most appropriate when the patient is already not sleeping very well and not sleeping very long, but the patient is also spending long amounts of time lying in bed while awake.

...

This is sleep restriction for insomnia. Whether or not it is widely misunderstood, it was not what I was referring to. I'll find some cites soon. Peace out.

In my limited experience, it seems psychiatrists these days are not as single focused on meds as 25 years ago. Seemed there was an unparalleled era of oversedation then. But even then, I wonder if it was just that the bad ones garner all the attention. Maybe there were many ethical ones even then who treated the whole patient, but those patients' lives went forward so successfully that no one even suspected they were under psychiatric care. I have a friend who is a psychiatrist, and I've found her to be an independent thinker, so no matter what was thrown at her in her training, she has sorted through it all to reach her own conclusions. In any occupations, there are good and bad performers.