Why We Can’t Stop Arguing About S.S.R.I.s

I don't think SSRIs are harmful, otherwise I wouldn't be prescribing them. But I do think that there are times when they're misused or they're not monitored safely enough or people have problems with them and we need to address them. And I certainly think that therapy needs to be available. If RFK and the current administration said we're going to devote a billion dollars to making sure that every child in America and their family has access to child therapists and in schools, not just in offices, I'm there. I'm David Wallace-Wells. I'm a writer for New York Times Opinion and a columnist for The Times Magazine. And I'm Rachel Bedard. I'm a primary care physician and a contributing writer at New York Times Opinion. One in six Americans is on antidepressants. A lot of Americans think that number is too high, that we're prescribing too many SSRIs, that we're giving them to children. Too young and that we don't really know how to get people off those drugs, even when they want to. The nation's top health official, RFK Jr., is kind of leading the charge. Health and Human Services Secretary RFK Jr. launching a new initiative targeting the overuse of psychiatric drugs, especially in children. The new plan urges doctors to prioritize holistic care like exercise and nutrition instead. But RFK and Maha are not alone. People have been debating. They've been debating these drugs and their effect on our society for decades. We're in a new moment now where people are arguing about it more. And Rachel and I have been talking a lot this summer about these issues. But that conversation is often at the highest level and ignores a lot of the clinical experience, what this looks like on the ground between patients, kids, their parents, and their doctors. As a primary care doctor, I currently work in a homeless clinic. I previously worked on Rikers Island in the New York City. In the New York City jail system, I've always worked in populations where there were very high incidents of comorbid mental health issues. And as a primary care doctor, I've prescribed antidepressants and medicines for anxiety to patients hundreds of times, probably thousands of times. And I've thought about these questions a lot myself around how I'm selecting patients who are good candidates for medicine. And when I'm choosing to medicate them, frankly, because I can't get them access to other services I wish I could get them access to, like talk therapy. So to hash this all out, we've invited Dr. Anthony Rostain to join us today. Dr. Rostain is the chair of psychiatry and professor of psychiatry and pediatrics at Cooper Medical School of Rowan University. Thank you so much for being here. I'm so happy to be here. Thanks. So let's start with some history. Where did SSRIs come from? Why did they seem like a very big deal? And how did they become so successful in the sense of so many Americans coming to use them so prolifically? Well, first of all, the SSRIs ushered, from my point of view, a new era in psychopharmacology. And when was that? It was introduced by the FDA, approved it in 1987. I happened to have been at 10 when it was being tested, so as I was a resident, and I saw that patients were taking it, were getting better, and that they weren't having side effects that some of the other antidepressants had. At the time, the primary antidepressant in use was, were in the classes called tricyclic antidepressants, which are still used occasionally. And they had a lot of side effects and potentially harmful side effects. Arrhythmias, people could accidentally or on purpose create situations where they would die from an overdose. So the fact that this medication came along, there was really, really tremendous relief at the ability to prescribe something that's safer and better tolerated. How they evolved is a whole story in and of itself of how science, medicine, and society evolved. Because initially, they were approved for primarily for depression. And little by little, the use was extended to anxiety, to obsessive-compulsive disorder, to social anxiety, and to PTSD. Suddenly, we saw many uses that we could use the same medication for. And we've all wondered in the clinical field, and in the general policy field at what point are we doing this safely? And I think it's healthy actually to be having this conversation right now. So you mentioned there in talking about that history, the contrast with the previous class of drugs, primarily in terms of the safety, that you could feel comfortable giving this to more patients, because the risk of some serious side effects was much, much lower. Back in time, we're imagining we're still in the late 80s, early 90s. How did the contrast, look in terms of efficacy? Was there also a marked benefit that hadn't been seen in the previous class? There was a sense that these were as efficacious and better tolerated, forgetting about the serious side effects. I think the overall early studies showed that yes, you could have a really good impact on moderate to severe depression with these SSRIs. I'm wondering if we can talk a little bit about mechanism and how the sort of theory of mechanism has changed over time. From one that was quite simple, the idea that the SSRI meant that you had more serotonin, a happy transmitter sort of soaking your brain to where we are now, where there's more nuance to how we think they work. Yes, yes. So it's true. I mean, I trained at a time when everybody had hypotheses. If you had schizophrenia, you had too much dopamine. If you had depression, you had too little serotonin. It isn't that simple and the brain is obviously more interesting and we understand it. Better than just a chemical imbalance. So what we think, number one, we know that all SSRIs do the same thing. They slow down the recycling of the serotonin molecule, which is a neurotransmitter, very important neurotransmitter. But what it really is doing over time is reshaping the circuits in the brain that affect our mood, that affect our ability to handle stress, that allow us to make sort of less reactive kinds of, of decisions. And over time, I think what, what we really come to look at is neuroplasticity is the term we use now. When we're stuck in a depressed state or when we're anxious all the time, we can't learn. Okay, our brains are locked into a pattern. And neuroplasticity is actually the mechanism by which we learn. So clinicians talked, we talked to our patients about the idea that if we give you this medication, not only will you feel less depressed or less anxious, but you'll be able to learn some new tricks. Right. And that's the idea is that this helps your learning in adaptation. And that's really interesting though, because the notion of depression as a chemical imbalance was sort of culturally accepted for a long time and was the way that people conceived of this. And frankly, was the way that I think lots of doctors spoke to their patients about it. There's a chemical imbalance and we can give you this medicine that will resolve that. I don't know that people think of depression as something where their brain needs to be rewired. And that idea can be pretty scary for people, I think. Of course, of course. What are you doing to, you know, that's what people want to know. Is this going to change my brain? And if so, you know, is that going to be a good thing? So what we're trying to get at, with depression, we sort of have this model in our minds now that the circuits in the brain that modulate your mood seem to not be allowing you to feel positively. And you're so stuck in this circuit of negative emotions. Actually, the brain has two different circuits, one for positive emotions, one for negative emotions. So one way I explain it to patients is to say, the positive emotional circuits are underpowered right now and the negative ones are running the show. This might quiet the negatives and allow the positive ones to be more present. Is it a permanent rewiring? No, because if we stop the medication, you go back to baseline. But hopefully, when you do come off the medication, say your depressive episode, is over with, you will have learned how to feel better and you will be able to push back against the negative more effectively. I think we're going to talk in a minute about going off the meds, but just to stick on this point for a second and to raise a kind of, you know, an ignorant, reflexive response. How strange is it that we developed this tool of drugs with one theory of depression, have evolved past that theory of depression, observe the drugs still basically working and are continuing to prescribe them. How unusual is that? How unnerving should that be? Do you understand it when patients express a lot about this? Let me say, to be quite honest, we still don't know what depression is. Or exactly how these drugs work. Right. And, you know, that doesn't stop us from using them because people are coming to our office saying, "I'm in pain. I need help." I mean, the same, by the way, is true for pain medications and pain syndromes. I mean, these are really interesting. The brain is a fascinating organ and, unfortunately, we have to simplify this because we don't have any better way of explaining it at the moment. With new non-pharmacologic interventions like transcranial magnetic stimulation, we can begin to think about, "Oh, maybe we can change your brain in positive ways without you having to be on a medication." So this is where some of my own, you know, sort of, I guess I would call it all of the kind of naturalistic fallacy comes in. I have some tendency to think, you know, If we understand the precise mechanism that, you know, insulin regulates blood sugar in the blood, I trust that it's appropriate to intervene when that's necessary. But if we're much more confused about the system, I have a little bit, you know, I have a little bit of a pause about the idea of taking meds like this and certainly prescribing them en masse as we've done. And I wonder if we could just talk a little bit about what we know at the level of population about how effective they are. How should we think about putting aside the mechanism, just looking at whether they're working or not? How, what's the kind of lay of the land, state-of-the-art understanding of that question? Well, to begin with, what we've learned from all the studies is that even if they are effective for a population, the patient in my office is going to have their own idiosyncratic response. So, therefore, it's not a one-size-fits-all. Like, no, SSRI don't work the same for everybody. So, these population studies tell us that there are good effect sizes. Not curative to everybody. There's still a lot of treatment-resistant depression. People who started on this medication and they're still depressed fairly commonly. And as a psychiatrist, I see the cases of people who haven't been effectively treated by the first line of treatment. The second thing, and this is really important, I always like to say, yeah, insulin and diabetes is a beautiful mechanism. We know it. And sickle cell, we know that. But what about hypertension? You know, what about risks for stroke? What about even obesity? We don't know how these things are actually operating. We know lifestyle affects those. But there's genetics as well. We don't understand the genetics of these disorders as well as we'd like because we don't really know how to translate the clinical phenomenology back to the genes or to the mechanism of whatever life did to you over the course of time that made it harder and harder for you to feel like I can get up every day. It's interesting because I also think we sometimes ask harder questions of the brain drugs than we do. If I'm taking a pill and it's like, this is going to reduce my risk of stroke by 80%, do I have to understand the mechanism? No, I'm going to take it. But something about the fact that this is affecting our brain makes us intuitively a little bit more worried. I mean, I think the brain is more of a black box and certainly amongst the organs we understand the least and we have the least amount of visibility into it. I also think that people feel that who they are is. It's located in their brains. That's right. And this anxiety that people have, I think that's quite understandable that if I take something that changes how I feel, does that change who I am? Or does that change aspects of myself that I don't want to change? And you don't feel that way generally when you're prescribed a high blood pressure medicine. I wanted to ask you, Dr. Osteen, when we're talking about efficacy, talk therapy is also effective and we think it works in similar ways, right? Well, I'm glad you brought that up because I was. First, let me emphasize, I think the ambivalence that humans feel about taking a medication that affects their brain is a healthy thing. We should always ask, is this the right thing to do? And is it, am I pleased or not with the results? And if I don't like what's happening, I better tell somebody about it. Because patients vote with their feet. They'll stop taking these meds if they don't like the way they feel or if they feel that the long-term effects are not what they're looking for. It's very hard to get access to therapy. That's right. Our mental health system is in crisis. Mental health in general in the United States is not in great shape right now. But the ability to get that therapy makes it really unbelievably challenging for patients who don't have good insurance or who don't live in cities where there are therapists. And so the tendency of most of us would be to say, well, let's get you started on this medication. But I see this a lot. And child psychiatry and pediatrics, we always recommend therapy because therapy actually works better and has longer-term effects on people's mood and anxiety. So that's where I would agree with the comment you made that if the goal is to be able to manage one's emotional states more effectively, then meds alone generally don't do the job. And I always say that to patients. Listen, I can start you on this medication. We're really going to talk about how are you living your life? What can you do to feel better? Behavioral activation is probably more effective than most medications. What do you mean when you say behavioral activation? Getting up every morning and doing something, moving your body, exercise. I mean, incredibly powerful studies show that if you get up every day when you're depressed and you start exercising, your mood improves. And if you do it preventively, people don't get as likely to get depressed just because moving. Moving your body is good for your brain. Right. There's sort of famously studies about the benefits of dancing being sort of as potent as some of the SSRIs, right? But as you're saying, I think there are two things. One is it's easier to get access to the person who can prescribe the pill than it is to get access to the clinician who can prescribe ongoing meaningful therapy. Or provide it. Right. And then the other thing is that the pill is the pill. Therapy is an incredibly valuable thing. It's an incredibly valuable intervention, right? And its efficacy depends so much on who's delivering it, the modality that they're delivering, whether you're doing something that's psychodynamic or whether you're doing something that's more cognitive behavioral therapy or, you know, whatever. And the commitment of the patient. The commitment of the patient. Huge. The relationship between the patient and the provider, all of those things. So it's one of the things that I think gets really murky here is we talk about categories. We talk about categories of interventions as though they have sort of inherent benefits when actually there's a ton of variability across therapeutic relationships around what you're actually getting. I mean, the field of psychiatry and mental health needs a lot of allies, okay? We need everybody, teachers, parents, you know, people in primary care to really ask the fundamental question, what's going to make a difference for this individual to get them out of the crisis? They're in to help them function better, to help them feel more hopeful about the future. And like I said, if you're living in a terrible circumstances, you have food insecurity or you have no real strong relationships because you're lonely, then that's where the epidemic of loneliness comes in, right? We're not going to give a lonely college student an SSRI and think that's going to solve the problem. The issue is going to be, no, you need to not only take the medication, but we need to help you find friends and or get somebody. We need to find somebody to support you in your efforts to succeed in what you're trying. I work in a homeless clinic now, and for years I worked in jail, and I was a jail doctor. And that's not a place where giving someone 10 of Lexapro is going to crack the case on the distress that they're living through, right? Exactly, exactly. So in a way, we could say that we have to address the social determinants and the relationships because I think Americans are suffering right now from a shortage of positive relationships. One other thing about therapy is therapy is not fun. Therapy is work. And a lot of patients find the work itself too difficult. So the therapy may be very effective, but is the person in the state where they can actually do the work involved in the therapy? And that's something we gauge all the time. And the third component is, along with that, is the social environment the cause? And if so, why are we giving? Why are we giving medication when, in fact, the cause is not in that individual? Well, one answer would be that it's a lot harder to intervene at a large scale in social environments. But I wanted to pick up on something you said a few minutes ago when you said mental health needs allies. And Rachel said in response to your saying about the sort of environment producing some of these effects, that's a very Kennedy-like statement. And I wonder how you think about this present moment where we have America's leading health official and a kind of— You know, loud social movement, MAHA, talking about these questions in pretty combative terms, whether you think that those questions are helpful, whether you think the movement is productive, whether you can count them as allies of mental health, or whether we should think about them in some other category. This is a—it's a complicated moment coming out of the pandemic. It is a critical moment. I think they're coming at this with good intentions. The best of them. I think that they're using a bludgeon instrument to attack people who are otherwise doing what their best they can to help others. So I'm very cautious right now in what I might even say on a broadcast. Because the way in which the MAHA report came out made it sound as if there is an epidemic of prescribing stimulants or prescribing— I think that's a good point. I think that's a good point. harmful, otherwise I wouldn't be prescribed But I do think that there are times when they're misused or they're not monitored safely enough or people have problems with them and we need to address them. If RFK and the current administration said, we're going to devote a billion dollars to making sure that every child in America and their family has access to child therapists and in schools, not just in offices, I'm there. Because we're so underfunded right now. We are so under-resourced in this field. And if you talk to my colleagues, whether they're psychologists, psychiatrists, social workers, we all feel assaulted by this approach. Rather than. Wanting to join it, right? Why don't you invite us in a way that isn't political to actually ask the basic questions? What's wrong with the way we're living? How do we improve our lifestyle? How do we build structures that are really meaningful to people, that get them to feel safe, that get them to feel like their lives have a purpose, and that help them when they're struggling without stigmatizing? Just to go back to, you mentioned the Maha report. So that was, for folks who may not know, that was earlier this year, there was a report about the use, the potential overuse of psychiatric medications, and then specifically around the challenges around deprescribing. That's right. And concerns about prolonged withdrawal that actually ends up making people feel worse than whatever. Whatever their initial reasons for going on the meds were. In response to that, I think for the first time, right, American Psychiatric Society got together and put out a statement, I think, about deprescribing. That's right. One sort of criticism I've heard that strikes me as somewhat legitimate is that that report was overdue. That thinking sort of seriously in public about the challenges around deprescribing is something that we should have done before we, in medicine, should have done before. Maha came out with its attack first. I agree 100%. I mean, we had not spent enough time asking the question, why are we giving so many meds to some of our patients, especially in psychiatry? And one of the first things I've always done when people come to see me is if they're on four or five different medications, the first thing I ask is, what can we take you off of? But it's great. Even if the prompt was kind of a smack in the head, it is time to ask, what medications are we prescribing? How are they working for our patients? And how can we safely get them off? Exactly. How do we safely deprescribe? Yeah. And so one of the things that I think is challenging is sort of there's a wide gulf between what best practice looks like and the way that these medicines are used and how they end up getting used in the real world. The best practice is that you would diagnose a patient, decide that they were an appropriate candidate to try the medicine in, counsel them about potential side effects, start them on the medicine, get them treated. And then once it had been working for a period of time and you thought that they were better, you would try to get them off of that medicine. They're not intended to be used forever. But what we know is that while most people do stop within the first year, we don't know why they stop. And we suspect that many of them stop because they didn't tolerate it or it didn't work for them. They didn't like taking it for some reason, not because they were getting that standard of care. And then amongst people who do stay on the medicine. They end up staying on for years. The median is something like five years. And for those folks, like that's not, the trials were not conducted over years long periods, right? They were conducted over short months long periods. So I'm wondering if you can talk about how you think about that, including how you think about sort of who should be on these medicines for years and then how that complicates efforts to get them off to do this deprescribing work. So the heterogeneity of. People and of diagnoses that we use the SSRIs for makes that answer to that question very hard. Okay. Um, for say a single episode of depression, the standard practice would be you stop it after six to 12 months of normal mood and you do it in a systematic way. How often is that actually happening? We don't know, but that's what the guidelines suggest when people aren't better or when they're better, but they don't want to. We have a different situation. Many patients will say, oh no, this is really helping me. Can I stay on? And what we answer is it seems safe. We don't know how long it'll work, but if you're doing well and you're choosing to stay on this, we can work with that. You're not going to say, no, I won't prescribe you your medication that seems to be working. Patient will not be happy with that. Okay. So we do have to work at what's are their beliefs about the medication? Is it worth the risk? Is it a risk to them or not? It's all about risk benefit. When we're talking about things like obsessive compulsive disorder, how long do you stay on that? It's much more difficult disorder to treat and therapy is indicated, but it's not always that effective. What about generalized anxiety? We hope for all of these kinds of disorders. People stay on the medication only as long as quote needed, but the needed isn't defined by number of months or years. And in the real world, I think I can tell you that at least in my practice, I'm always asking the patient, do you feel ready to come off the medication? And if they say no, I ask them, why don't you feel ready? And if I think they should, I try to engage them in considering slightly, you know, a slight reduction. And how do you make that assessment? Well, an interview, ask them how they're doing and scales. We'll use standardized scales. But what I mean is like if you're talking about two different patients, one of whom you think should stay on. One for long duration and one you think is a good candidate for tapering or what distinct, what distinguishes those two cases for you? Well, how they're functioning in the world. Are they, do they have the supports in place? Have they learned the skills? Are they in fact truly free of that, that whatever condition they were having at the time. And in terms of the natural history of what's wrong with them. Like, for example, I see, I see people with Tourette's syndrome and anxiety and OCD. And depression. Um, well, their brains are a little bit more wired differently than the rest. So with them, I'll say, Hey, you know, you may need these medications longer than what, six months or a year. How are we going to work out a plan for deciding together? And then when we do, we have to decide very slowly how to taper versus someone who has a single episode of depression. It's not as complicated for them to stop the medicine. Okay. When you're, when you're thinking about tapering. When you're thinking about tapering, what are the worries there? I mean, it seems to me like every few months, there's a kind of a new viral essay, someone saying I tried to go off my SSRIs and I had a really hard time. Okay. So now we're talking about discontinuation syndrome. Like you mentioned a moment ago that a lot of patients just take themselves off the meds and some of them will just go cold Turkey and they'll just deal with the, whatever it is. And they don't experience a major problem. So there is a subset of individuals. And I believe it is more like genetically determined. They won't do that. Well, when we stop this, how had their brain adapted to it, where you have to go very, very slowly. And so that's what we're learning now is that the rate at which you stop the medication can really make a difference as to whether you can do it successfully. There are people who I'll give you one quick example. I have a patient who I've known since he was a little boy, and then he came back to me as an adult and he was taking, um, as the. Uh, when he was younger and he was having some sexual side effects as a young adult. So he tried to take himself off of it and he experienced terrible discontinuation. So he came back to see me and we've been working together for about a year to figure out, okay, how do we lower you slowly? And he's going down by 0.2 milligrams of his dose every two months, because going any quicker. Leads him to have major, major anxiety, panic. And how much is that discontinuation syndrome versus, um, just that his, that his underlying nervous system is not quite regulated. And when he comes off completely, he might, he might have to stay, go back and make that decision to go back on because his nervous system doesn't quiet itself. Dr. Hussain is a pediatrician and psychiatrist and particularly interested in how you, um, think about these issues. They apply to children and adolescents in whom we have even less data maybe than we do for adults to guide our decision-making. One of the charges that the Maha movement makes and others, I think, agree with is that we're over-medicating kids. How do you think about that? Well, I think we have to take that question seriously, but not lead it as a conclusion because ultimately what is the right amount of prescribing of these medications is not something. I don't think anybody has an answer to right now. So it's gotta be boiled down to a few questions. Number one, why are we using a medication with a child who has behavior problems or mood disorder or learning difficulties? Is there a bonafide reason for using it? And once we do. we decide we're going to use it, is it working without major side effects? Every parent worries when they start their children on a medication, am I doing the right thing? And we don't need to make their decision-making even more complicated with accusations that they're doing a bad thing. I don't think this should be part of a moral discussion here. It's a practical question. Medications are a tool. Does this tool work or not for your child? What are the risks? We have to bring the risks to the table, but also what are the benefits? And ultimately what every parent has to do is decide in the benefit-risk analysis, the benefit outweighs the risk. And then to see if it's actually the case. Because if we're not listening, not just to the child or the adolescent, but to the teacher and the parents, for example, who are observing that child, then we as the prescribers aren't making good decisions. We need data. Give parents the whole blueprint and then get feedback from the child as you're going through this, because kids will have opinions and that's important to us, right? If the child says, this is really helping me, okay, that's really important. If the child says, I don't like the way this makes me feel, or this isn't helping me, we need that information. And then the last thing is, I'll just think that the question we've asked all along in this conversation is, are Americans really trying to find answers for medications that they, they need to find from other aspects of life? Are we over-relying on medicine as opposed to over-medicating? So when we think about side effects and worrying about side effects, what are the big common side effects that people worry about, that you worry about? So when you start the medicine, you might feel nauseous. You might have GI upset. There's a possibility of weight gain on some of these medications. Sexual side effects are the big one. Decreased sexual desire, trouble with orgasm. There's also the problem of having kind of this emotional blunting where people don't feel like they're themselves. There can be sleep disturbances. In some individuals, you can actually become activated and become feeling too good. And that might be a sign of, you know, something else is like triggering a mood episode in you. And then there, I guess the other is a sense of fogginess, not being able to concentrate. And then I guess the other is for the black box warning that was put in the early 2000s that there were reports from the trials that occasionally individuals felt like they were thinking about suicide more. So back in 2003, 2004, the FDA said, okay, we got to warn people that this could cause suicidal thinking or suicidal ideation. Everybody got worried about that. And a lot of primary care practitioners and pediatricians and family physicians and internists who were prescribing these medications backed off, especially for kids. And at that point, we saw a rise in the subsequent years of adolescents presenting to the emergency room with suicidal thoughts, not because they'd been on these medications, but they'd had a harder time getting started on them. So we kind of, we still have the warning, but I think people don't use the warning as a total don't start this. We're like, okay, just be aware of it. And it's, I think it's finally been integrated into best practices. So watch for this, but it's led, I think, primary care to be more comfortable once again, using it as indicated. It's one of the things that I find quite tricky as a prescriber here, which is the risk benefit weighing is quite complicated. And that's true for the withdrawal piece as well, right? That when people are coming off, it's quite hard to distinguish, are they feeling bad because their underlying depression, anxiety, OCD is sort of rearing its head? Are they feeling quite bad because they're withdrawing from the medicine? I find there's a lot of diagnostic uncertainty here. I think it's important to recognize that and be humble about it and be honest with patients about it. The choice to stay on a medication is ultimately the patient's. We will make modifications if they're saying it's not working, but we also have to be honest with them that we can't predict if you're coming off of a medication, you might experience a discontinuation syndrome, which is where you feel lousier. You just don't want to do anything. You know, you really feel worse depression or worse anxiety. And so what I generally say is that that's happening. We will slow the rate of decrease down. But I think diagnostic uncertainty is the nature of the game. And I think our, we're not, we're not, if we're not honest about that, patients are going to know it. Can I ask you to just pull back on diagnostic uncertainty for a second? Because one of the features of this moment, I think, is that we have a kind of conventional wisdom sense that rates of mental illness are dramatically up over the last couple of decades, maybe most dramatically among kids, but across the population as a whole. And in some crude way, that's true. The lines are higher than they were in the past. But I'm also, I've always been suspicious about what that really means and codes because. We're living through a period in which so many more people have access to healthcare. The taboo against treatment is so much lower. You see, you know, variable access in different communities that tells you that, you know, the actual number of people getting diagnosed with major depression or anxiety has to do with a lot of stuff other than how much they're suffering and how much distress they're in. How do you think about this big picture question? When people talk about mental health crisis, how should we make sense of it? I've checked some textbooks that I read when I was in training and also in the early 2000s, and there was a mental health crisis back then. It's been part of the modern world. I think what's changed recently are factors like the pandemic, like the globalization of the economy that leads everybody to feel wondering where am I going, am I going to have a job in the future or not? And I think the breakup of communities and of families and the atomization of our society. So I'm always aware of that. I feel that where am I in the world is a question I think people ask themselves a lot. And I think they have to have somebody to talk about that. And that will make their choice, their decision-making better. So I always, I think the number one question we have to ask people who are depressed is, do you have anybody to talk to? And if so, are they able to listen to what you have to say? And if they say no, they say, okay, we have to do something about that. With respect to the growing acceptance and the destigmatization, I'll say that's good news. It's really good news that people are not as ashamed about admitting that they have a mental illness or a disorder, but there's still tremendous stigma in some of our communities. Still, people will not go for help. And that to me is worrisome because the shame that people feel when they don't feel like they're doing the right thing or they're not measuring up to others, if they're not able to confront that and say, I need help with it, to me, that's a very big risk factor. Do you worry at all about a diagnosis being kind of self-perpetuating or self-creating? Yes. So that's the other thing. The search for identity that we talked about earlier, sometimes people search for identity through a disorder. Instead of, I have this disorder and I need to do something about it. So where does, how much do we identify ourselves with this thing called depression or ADHD? I think that's dangerous. I think we need to say to people, you have a condition that is a reflection of, you know, your mind, your brain, and your past and your way you've grown up that leads you to do certain things, feel certain ways, and think in certain ways. And we need to understand better what's the role of medication, what's the role of therapy, what's the role of changing your life lifestyle, or you're getting out of the situation you're in. And all of that means you have to start to make some decisions. The last thing I'll say is I see medications as a tool. They're not magic pills that solve everything. And some people would like that to be the case, but they're tools. And if they're not working, then don't use that tool, you know, tools to help us change. And I really do believe the ultimate answer to what you've been asking is in the future is that, yeah, we'll have better ways of mapping the disturbances in the brain, et cetera. But we do know that if you don't have a good social support system, and if you're not living a healthy lifestyle, and if you don't know, you know, what your future is going to look like for you, you're more likely to suffer from a condition we would call anxiety, depression, or some variant there. I also think that from my standpoint, unless society invests in training people, whoever they are, in whatever place they are, to feel comfortable talking to people about how they feel and what's going on with the individual in a way that enables them to feel like they have somebody they can trust, without that, you know, we're going to still have this problem in 10 years or 20 years. Fundamentally, I'm a humanist. Human beings have to figure out for themselves how to make the world a livable place. it to one another, to have a commitment to that. Medications can be used in an anti-humanistic way, and I don't think that's right. Yeah, I mean, one way of reading that story is to say we're trying to solve a problem with a pill that we should be solving in other ways, but another way of looking at it is that our society is jagged and imposes pain on people, and the work of repairing that is going to be complicated, piecemeal, generational, and, you know, in the meantime, we have a lot of people who are struggling. Right. I'm wondering if you, you know, if you had RFK Jr.'s ear, or if you were, you know, empowered to think about what the first step should be towards a more effective and humanistic approach to this crisis, do you have ideas about where you'd start? Yeah, yeah. I mean, I think family support and education and schools need a lot of help right now with kids coming to school who are in crisis. Same in workplaces. Yeah. I think everybody. Every place right now needs to ask, are we doing the best we can to keep the people who are here healthy? And I would come at it from a health perspective, a public health perspective. And then those that are struggling, get them the help sooner, because don't wait till the bottom falls out. So, yeah, I would tell RFK, I would love to hear, you know, what you're thinking of when it comes to really providing the resources to families. That will enable them to eat better, that would enable them to spend time together, that they won't be constantly feeling like they're always, you know, running to stay in place. And how do we teach families about mental health? It should be done right from the start. Right. I think RFK really needs to demystify what we know about the brain, how we can improve our brains, and then how we use medications, how we use therapy, and how we use what I would call social support structures to improve our mental health. I think that's a great place to end. So thank you so much for coming and talking to us today. Thank you for having me. Thank you.