Can You Cure Depression with this One Weird Trick?
Can You Cure Depression with this One Weird Trick?
Psychiatry might not care if Monday’s blue, but patients are waiting for the Cure
Behold, the TL;DR—
Psychiatry sucks at communicating. We don’t trust mental health treatment to be curative because we shouldn’t, and it’s not.
FDA Breakthrough treatments like SNT neuromodulation by Magnus Medical have the potential to relieve suffering vastly more than current treatments.
Read on:
Let’s pretend I was going to try to defend the click-bait title of this post. It could start with the level of off-putting defensiveness modern medicine tends to favor. I could emphasize credentials, and bully my audience into agreement…and for the sake of the argument, I’m going to do just that:
Hi there. It’s DOCTOR Muir. Not Mister. I am a psychiatrist. No, Not a psychologist—different. I went to medical school. I am a board certified child and adolescent psychiatrist. That’s actually two board certifications. I swear to God —That title is literally true. This is not a scam. I am going use the word cure. You may remember it from language that is popular with scam artists.
I’m an Inauspicious Star!
You likely cringed. My wife—also a psychiatrist—has already cringed. Several. Times. After all, I used the C word: cure.
To mark my intentions, this is not an article about the word cure, or about a specific “cure for depression.” We are not even reliable at diagnosing depression in the first place. Those things will be but characters in the story.
This is an article about psychiatry’s narcissism, lust for “sciencey credibility”— and how a closet full of white coats is just as flimsy as the emperor’s new clothes when “winter is coming.” The real helpers will be appropriately garbed,
…and have a willingness to actually stand up to the white walkers that are mental illnesses’ closest pop culture analog. More Dr. Jon Snow and his resurrections from the dead, less cringey life coaching from Cersei Lannister.
Outlandish Claims!
“You can cure depression”…If I was employed as a pharma rep I’d be fired already. But if we imagined there was such a thing, I doubt we’d even be able say it. This is not a new problem in medicine.
We similarly screwed up the ratio of amazing science to terrible communication strategies with Covid-19. I did a whole podcast series about Covid-related messaging weirdness. To quote Dr. Jha, the White House covid response coordinator:
"Because we weren't sure, we led with, 'We don't know,' which was assumed to mean 'no.'"
Going forward, Jha said, public health officials — including himself — should make concerted efforts to lay everything out on the table. Often, he said, people don't necessarily need certainty. They need a judgment call from a trusted source.
Our efforts, in mental health as in public health, are focused on “avoiding sounding scammy” at the cost of clear, convincing communication.
It continues to be fashionable, in my favorite magazine of all time, to express the belief that psychiatry can do little good as a medical discipline:
Still, for the many of us, like myself, who slog through days and months filled with unbearable sadness or destabilizing mood disorders, the lack of a thoroughgoing solution is in itself despair-inducing. One can unburden oneself to a therapist, swallow a bunch of meds that sort of help, or go to an emergency room and wait to be admitted to a bare, neglected psychiatric unit that couldn’t be more inclined to worsen one’s state of mind if it had been built as a detention center. (The Atlantic, July 10th, 2022).
What is even sadder is that I agree with everything the author shared above. It’s a dismal journey when the only options offered suck.
So for most sufferers, whether they write think pieces in fashionable magazines or not, a depression cure is unbelievable. Frankly, we wouldn’t know what a cure was if it hit us in the face. Psychiatry has long since got out of the business of relieving suffering. At best, we solemnly “manage” your misery. Our efforts to communicate with advertising have gone from scam-thusiasm to visually appalling and lame.
We went from ads for placebo fortified with laudanum like this:
To this (creepy and stigmatizing) ad in the 1960s:
To this inspiring conversation about Abilify in the 2000s… Is it a message of marginal hope dramatized by “anthropomorphic pill” and “refugee Capital A” from Sesame Street?:
And, of course, this blistering attack on “all design aesthetics.” Note the choice of copy-writers—chosen, I presume, for the same relationship to exciting prose that McDonald’s has to Michelin Stars.
This makes sense when we spend time with the data around the limited effectiveness of these interventions, or listen to sufferers (again, Daphne Merkin in the Atlantic):
As someone who has spent decades both in psychotherapy and on a panoply of psychotropic medications, I would say that although they haven’t succeeded in undoing the damage and repercussions of my past, they have been significant in making my life more tolerable.
Evaluation and Management of Expectations
Most oral medicines work modestly, and almost no one, including psychiatrists, even think of curing depression. We refer to the work we do (in billing and coding) as “evaluation and management.”
Q: “How is that depression treating you?”
A: “I’m managing…”
Q: “let’s continue with the evaluation?”
Grim. And that’s before we talk about the massive weight gain and other side effects of antipsychotic augmentation and other dubious strategies.
Introducing, The Magnets
However, we do have a more effective treatment in the FDA Breakthrough Pipeline:
The treatment I’m referring to was on the Today show last week. The producers refer to it- and I wish this was a joke- as “Magnet Therapy.”
The Today Show is attempting to cut graphics costs by using, presumably, the “Russian-hack-job-only” pricing package on 99designs to develop this:
With a moniker like “magnet therapy,” mention of a cure is seeming about as scientific as tiger-penis/black-rhino-horn combo pill remedies for erectile dysfunction.
Given how stuck we are for words, I’m going to put the dictionary definition of “cure” here so maybe we can find a useful synonym?
And the “magnet therapy” research I’m about to describe, if replicated, actually meets every definition of the (transitive verb) meaning of the word cure as it applies to depression as an illness—though, in all fairness, not to leather or jerky related uses of the word “cure.”
“Cure her of that!” (Macbeth, Act 5, Scene 3)
When we use that term in medicine, we generally are referring to things that get better and don’t ever come back. This is not the same as the dictionary definition of the word. Shakespeare’s Macbeth wanted a “cure” for his lady wife, with her psychotic symptoms at least plausibly related to psychiatric illness:
“Out, out, damn spot!”
Three main criteria were described by psychiatrist Karl Jaspers for delusions:
The false belief is held on with absolute certainty.
Despite the proof that it is false, the belief is not changed or corrected.
The belief is false, bizarre, impossible and implausible.
Doctors worry about endlessly about if we will over promise and under deliver. Snake oil is not supposed to be what we sell! So we have, in the field of psychiatry, abandoned the word “cure” based on the delusion that this makes us more believable. We talk about “response” to treatment. If we use the term “remission” we mean “the symptoms of the condition are no longer present” but we feel satisfied that we haven’t over promised— remission can always relapse. These linguistic choices are limiting, in that the snake oil sales people are the only ones in the market of ideas allowed to make strong statements that humans find relatable.
I also think the choice to limit our language to “response” is also misleading—it leads us to think “response” (generally defined as a 50% reduction in symptoms) is a laudable goal. It’s not. We run endless studies with “response” as an endpoint. Personally, “response” can go to hell as a primary endpoint. Viva La Remission!
“Suffering—now up to half-off!” isn’t good enough. Scam artists sell “cures” because people want to not suffer any more. They don’t want to suffer “somewhat” less.
My Preposterous Sales Pitch for “Magnet Therapy” Continues…
Given the difficulty of describing what a cure might be, one of the most replicable findings in neuroimaging is that colored pictures of brain scans make things more believable, so let’s try that?
If we take a picture of your brain thinking in real time, using functional magnetic resonance imaging (fMRI), we can use that data and artificial intelligence to predict precisely where to point our “magnet therapy” machine so as to maximize the chance that your depression remits.
I have a medical license. I am totally, totally not lying about this. I will make further implausible claims about this treatment for depression:
works in five days or less
leads to remission for >50% people.
doesn’t require any medication.
doesn’t require talk therapy (though it may be helpful afterward).
is safer than water (in that you can’t overdose) and is considered a minimal risk procedure by the FDA.
lasts for months to over a year for some.
Really, Magnet Treatment?
What they describe on the Today Show involves strong electromagnets placed on the scalp, targeted by AI interpreted fMRI imaging of your brain. It has close to no side effects over the medium to long term, and in the short term it’s uncomfortable for some people, and there’s a theoretical risk of seizure, but that’s it. Oh, you can have hearing damage because it might be kind of loud if you don’t wear ear plugs. The risk profile of the both the most effective treatment ever studied for depression and going to Coachella (potential hearing damage, fatigue, headache, boredom, about 5 days out of your life that you will never get back) are about the same.
Do you believe me?
Well, I have one more thing to say that might make me seem believable before I pull back the curtain on the randomized controlled trial and other research evidence that back up what I’m saying:
But it kinda should, right?
You can’t handle the truth!
What I’m describing is a a treatment that goes by the brand name of SNT, which is short for Stanford Neuromodulation Therapy. The generic description of it, if we’re not including the using the picture of the brain to point at the right spot plus artificial intelligence bit — is a pattern of stimulation called accelerated intermittent theta burst stimulation using a device called a transcranial magnetic stimulation (TMS) machine. TMS is like saying “medicine,” and the pattern of simulation is the type of medicine. Prozac versus penicillin. Both are medicines, but clearly not the same kind of medicine.
TMS, as a once a day treatment for depression for around 6 weeks, has been FDA cleared since 2008, and works very well. SNT treatment is not yet FDA cleared, but it does have FDA Breakthrough status, which means it’s so promising that the approval process has been sped up.
Referring to this as an “experimental treatment,” in this context doesn’t mean “we don’t know if it works” in the same way it’s disingenuous to say that the theory of gravity is “just a theory.” YES, this is a treatment that has to go through an appropriate regulatory pathway. When it is broadly offered, we will thusly understand enough about the risks and benefits to be able to offer it to the right people for the right problems at the right times. BUT…
It is worth knowing that hundreds of patients have already gotten either this treatment or variations thereof and their lives have been saved. One of the remarkable features of the research done thus far is that Dr. Williams enrolled patients with such severe treatment refractory depression that the rate of placebo response in his research subjects was, in all practicality, zero. This is a dramatic departure from traditional studies on treatments for depression which typically have high placebo response rates. It allowed the statistical demonstration of results that are groundbreaking with very few patients enrolled in the randomized controlled trial. In order to pull this off, hundreds of people got the treatment on an “open label” basis first, and the randomized controlled trial followed. What this means is that the refrain of “much larger studies are necessary to prove…” is actually statistically BS in the case of this treatment. We need to do more research to replicate results to make sure we’re not looking at a statistical fluke or forgery, and we need to understand more about what happens in individuals who don’t suffer exactly like the very well selected research subjects. But we don’t need giant placebo/sham studies. It would likely be unethical to do them, in that it would require withholding treatment that is demonstrably effective from research subjects who could benefit from it. I mentioned a similar IRB intervention to stop a study early in my review of ADHD treatment in my prior article on Cerebral.
Eternal Sunshine of the Damn Spot
Part of the privilege and burden of being a physician is that “saving” anyone from misery, death, and suicide is not entirely ours to do…just listen in to Shakespeare’s Macbeth + Doctor speaking of Lady Macbeth’s troubles (Act 5, Scene 3):
MACBETH
How does your patient, doctor?
DOCTORNot so sick, my lord,
As she is troubled with thick-coming fancies
That keep her from her rest.
MACBETHCure her of that.
Canst thou not minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuffed bosom of that perilous stuff
Which weighs upon the heart?
DOCTORTherein the patient
Must minister to himself.
Our Doctors’s tools to meet Macbeth’s lofty expectations were limited. “Rooted sorrow memory extraction” is still the territory of Eternal Sunshine of the Spotless Mind and related fiction. So for physicians like myself, who work with patients for whom care algorithms have long since run out, there is some degree of “trying different stuff“ that we are allowed to do, with informed consent, outside of rigorously controlled studies. The art of medicine exists because we recognize that alleviating human suffering requires individualization when we can’t know everything.
However, if Lady Macbeth had SNT covered by her insurance, more than “ministering to himself” may have been possible:
I believe that SNT and similar approaches will demonstrate both statistical significance and be—capital H—Helpful. The side effect profile is also shockingly better than that of oral medications. We already reviewed that wildly effective treatments require much smaller studies to be statistically borne out:
To make it clear for general audiences the level of faith I have in “amazing” being the outcome of subsequent research, it is near the level of faith I have that “my landlord will expect me to pay the rent next month.“
It’s possible the randomized control trials won’t demonstrate the results I am expecting from having personally treated hundreds of patients with a close analog of SNT, with similar outcomes. And we do studies for the same reason I pay my rent: although it is safe to assume that some thing that happened reliably will happen again, for things that really matter like “not killing yourself because you’re so depressed” and “not getting evicted,” you make choices based on conservative predictions about the future.
Science: it’s a belief in the power of systematic doubt.
A treatment that reliably gets depression to remission—when other things haven’t helped—is huge. The irony is that we are unprepared as a field of medicine, or even a field of human endeavor, to describe this Very Big Deal in a way that is believable (with apologies to Winnie the Pooh).
Too good to be true
Much like our utter failure to communicate how important Covid-19 vaccination is compared with the success of aggressive pseudo-scientific misinformation campaigns, leading to countless deaths and endless mistrust, the effort the field of psychiatry will put into sounding overly-cautious about empirically validated and wildly effective treatments will be a poor choice.
Not sounding like a scammer is important. But the actual thing health professionals, industry leaders, investors, and researchers should be spending our energy doing is…
not being scammers.
Health innovations should be helpful. Novel Treatments that change peoples’ lives for the better by A LOT need to be prioritized.
We fall back on the concept of “evidence-based“ or in more common terminology, “does this work?” We ask that question a lot. And we don’t think much about the answer, or the corollary “but will I feel better, doc?”. By fetishizing statistical significance, we miss out on what is the much more human and important outcome—does this work “a little” or is it a Very Big Deal?
Statistical significance: we have set a cut off, and that cut off is 5%. This is the risk we are willing to accept of any given study being accepted as positive when it’s really bullshit.
We realize we can’t perfectly differentiate between random chance and truly different. If you flip heads or tails on a coin, you’re going get some studies of 100 coin flips to have surprisingly more heads than tails. This is how random chance works. Statistical significance is a concept that let us say “this difference we saw probably wasn’t due to chance.” When we replicate a statistically significant study, we essentially do it all over again, and the chance that we were wrong—there is no real difference—becomes even less if there’s a 5% chance of being wrong by chance again. 5% of 5% is little enough (0.25%) that we’re basically “cool with” making that an approved treatment.”
“Statistical significance” is to scientific research what “Yelp reviewed” is to restaurants — important but not complete information.
Human brains aren’t really into statistics. It is more of a gut check kinda organ. Brains wanna see something that works, and then believe it till we die. Our brains are looking for “ride or die Homies,” not endless uncertainty. Furthermore, if we hear someone we trust tell us about something believable, it saves a lot of trouble as humanity. We are wired to have an on-ramp to new information with a big gate right in the middle of the entryway. The purpose of this gate is to keep bullshit, scams, liars, charlatans, and people who mean harm out of our minds. Just like rap songs featuring T-Pain are forced to be in tune, being attuned to the trustworthiness of information means we listen to less information that is “off key”. We are suspicious, because we should be:
Believing everything is not adaptive. So we have this big gate right up front that opens if trust is established. And once that trust is established, we believe basically anything.
So this, in my opinion, is the point that’s missed by the medicine communication police. It is not missed as the bread and butter of charlatans. Scammers understand that trust has to be built, and the right language can build that trust.
So they focus on trust building. Scammers can sell something that you trust will work. It doesn’t need to actually work. That is why scamming is a good business opportunity if you don’t care about ripping people off. People are never purchasing just the product. Scammers sell trust—The kind of “proven Snake Oil by Alex Jones” is immaterial.
The institution of medicine is trying to sell measured outcomes. This is in the service of not being a scam. By ignoring trust, however, not only do we do a terrible job of “sales,” but we actually sell more things that don’t work very well, further eroding trust in what we do.
We don’t expect depression to be curable. So what we’ve been conditioned to expect is that treatments don’t work very well. “Maybe a little?” is the amount of relief that we have grown to trust.
These are assumptions we take for granted.
It is appropriate guidance that extraordinary claims require extraordinary evidence. It is also incumbent upon us to understand what extraordinary evidence would even look like, so we can recognize Dr. Godot upon arrival. “Don’t believe everything you read” is a useful maximum, but it is not comprehensive guidance. “Believe some of the things you read, and not others.” Just add judgment!
I am a scientist. I think science is awesome. The willingness to change what we think when new evidence comes along has done more good for humanity than almost any other memetic system.
We evolved as social creatures to evaluate information rapidly based on who was presenting it. If we trusted that person, we trust the information.
Dear Psychiatry: Stop Offering Coping Skills to People in Burning Buildings?
Treatments in healthcare need to be proved to strict standards, and those treatments need to be communicated in a way that’s trustworthy. But the treatments have to work meaningfully well to be socially relevant. A cure for depression that no one believes will work—remember Abilify’s breathlessly excited anthropomorphic pill and his ray of hope?: “some patients experienced symptom reduction”— is just as useless as no cure for depression at all.
As Bill Shakespeare reminded us: all that glitters is not gold. We trust bling though, and trust is a really fruitful area of science as demonstrated through the work of the clinical psychologist Sir Peter Fonagy:
As well as Simon Baron Cohen, and others. Even entertainers like Sacha Baron Cohen teach us about trust through playful fooling the trusting minds of others:
Once we start taking trust as seriously as Sacha Baron Cohen takes messing with guests who inexplicably trust him—we get to a better world. He trusts us to “get it,” which is the opposite of the attitude taken by academic psychiatry and it’s disciples.
Physician leaders need to stop being jerks—their refusal to convincing us is no virtue. We can’t expect science to have the same built-in degree of convincingness as God, or whatever the hell they put on the iPad that makes my children want to look at them all the time. I’m looking at you, Roblox.
At the same time, scientists can’t treat research like buzzfeed clickbait—if it’s trivial research on things that barely work, please don’t waste all of our time. It erodes trust so we have more trouble believing Very Big Deal findings.
The Meta-Call to Action
Thank you for joining me for this article, and if you enjoyed it, please consider subscribing to the Substack you have just read and sharing it with your friends. This is known as a call to action in marketing, and I feel really awkward doing it. Everything you learn as a doctor tells you not to be a marketer or— heaven forbid—sales person. And yet if I don’t encourage you to share this piece, you’re less likely to do so.
Don’t forget to subscribe! Pay me money! Share with your friends! Trust me, it’s totally worth it…
Yeah, it’s exhausting. We live in a world where Joe Rogan has a bazillion followers. If you read this far, you might agree that it would be a different world if Dr. Muir and JRE switched subscriber numbers. Like Freaky Friday, but for audience metrics. As painful as asking you to share this article is, it’s way better than depression. Depression sucks, and we shouldn’t put up with it any longer than we absolutely have to. And I hope in the very near future that standard is going to be about five days:
—O. Scott Muir, M.D. (with edits to calibrate the snark : science ratio by Carlene MacMillan, M.D.)
Grateful to have an authentic and humorous perspective pushing the status quo of psychiatry forward! Thank you DOCTOR Muir!
A corollary to this is the "therapist vs. life coach" messaging disparity. Life coaches are often far more charismatic and engaging in their marketing and subsequent sessions than therapists, and we in the counseling profession would do well to recognize that our evidence-based modalities, such as EMDR, can be communicated in more exciting ways that evoke trust.