THE JOYFUL REDUCTION OF UNCERTAINTY

Mental Health On A Budget

Everyone knows medical care in the US is expensive even with insurance and prohibitively expensive without it. I have a lot of patients who are uninsured, or who bounce on and off insurance, or who have trouble affording their co-pays. This is a collection of tricks I’ve learned (mostly from them) to help deal with these situations. They are US-based and may not apply to other countries. Within the US, they are a combination of legal and probably-legal; I’ve tried to mark which is which but I am not a lawyer and can’t make promises. None of this is medical advice; use at your own risk.

This is intended for people who already know they do not qualify for government assistance. If you’re not sure, check HealthCare.gov and look into the particular patchwork of assistance programs in your state and county.

I. Prescription Medication

This section is about ways to get prescription medication for cheaper. If even after all this your prescription medication is too expensive, please talk to your doctor about whether it can be replaced with a less expensive medication. Often doctors don’t think about this and will be happy to work with you if they know you need it. They may also have other ways to help you save money, like giving you the free sample boxes they get from drug reps.

1. Sites like GoodRx.com. This is first because it’s probably the most important thing most people can do to save money on health care. For example, one month of Abilify 5 mg usually costs $930 at Safeway, but only $30 with a GoodRx coupon. There is no catch. Insurances and pharmacies play a weird game where insurances say they’ll only pay one-tenth the sticker price for drugs, and pharmacies respond by dectupling the price of everything. If you have insurance, it all (mostly) cancels out in the end; if you don’t, you end up paying inflated prices with no relation to reality. GoodRx negotiates discounts so that individual consumers can get drugs for the same discounted price as insurances (or better); they also list the prices at each pharmacy so you know where to shop. This is not only important in and of itself, but its price comparison feature is also important to figure out how best to apply the other features in this category. Even if you have insurance, GoodRx prices are sometimes lower than your copay.

2. Get and split bigger pills. Remember how a month of Abilify 5 mg cost $30 with the coupon? Well, a month of Abilify 30 mg also costs $30. Cut each 30 mg pill into sixths, and now you have six months’ worth of Abilify 5 mg, for a total cost of $5 per month. You’ll need a cooperative doctor willing to prescribe you the higher dose. Note that some pills cannot be divided in this way – cutting XR pills screws up the extended release mechanism. Others like seizure medication are a bad idea to split in case you end up taking slightly different doses each time. Ask your doctor whether this is safe for whatever medication you use. Do not ask the pharma companies or trust their literature – they will always say it’s unsafe, for self-interested reasons. Contrary to some doctors’ concerns, this is not insurance fraud if you’re not buying it with insurance, and AFAIK there’s no such thing as defrauding a pharmacy.

3. Mail order from Canada. Canada has lower prices than the US for various prescription drugs. Canadian pharmacies are unlicensed and illegitimate and you should never use them, according to the same people who tell you that marijuana is a gateway drug and porn will fill your computer with Russian viruses. According to everyone else, including most doctors I know, they are fine as long as you avoid obvious scams. They are technically illegal but the FDA has a policy not to prosecute people who buy drugs there for personal use. The Canadian Internet Pharmacy Association maintains a list of ones they consider safe. If I try really hard, I can find a way to get the month of Abilify 5 mg for $4.58 from canadapharmacy.com, but this isn’t really that much better than the best American option. Some other medications do seem to be better, especially ones that are still on patent; if I want a month of Saphris 10 mg, the best I can find on GoodRx is $620, but on canadapharmacy.com there’s a deal for $196.

4. Pharma company patient assistance programs. As part of their continuing effort to pretend they are anything other than soulless profit-maximizing bloodsuckers who will be first against the wall when the revolution comes, some pharma companies offer their drugs for cheap if you can prove you need them and can’t afford the regular price. These are most useful if for some reason you need a specific expensive brand-name drug; if you have any other options you’re better off just buying the generic. You can search for these programs at Partnership For Prescription Assistance, RXAssist, and NeedyMeds. Be very careful to read the fine print on these, because no matter what they pretend, drug companies are soulless profit-maximizing bloodsuckers who will be first against the wall when the revolution comes, and sometimes these are just small discounts that aren’t as good as using one of the other methods. Occasionally a company will give you a great discount that knocks a brand-name medication costing $300 down to only $150 without telling you that there is a similar generic that costs $5. But if you need one specific very expensive thing, and you are lowish-income, and you don’t have government help, this is still your best bet.

5. Get 90+ day supplies. If your insurance charges you a co-pay of $30 per prescription, and you get a 90-day supply instead of a one month supply, then you’re paying $30 once every three months, instead of once a month.

II. Therapy

This section is on ways to do therapy if you cannot afford a traditional therapist. There may also be other options specific to your area, like training clinics attached to colleges that charge “sliding scale” fees (ie they will charge you less if you can’t afford full price).

1. Bibliotherapy: If you’re doing a specific therapy for a specific problem (as opposed to just trying to vent or organize your thoughts), studies generally find that doing therapy out of a textbook works just as well as doing it with a real therapist. I usually recommend David Burns’ therapy books: Feeling Good for depression and When Panic Attacks for anxiety. If you have anger, emotional breakdowns, or other borderline-adjacent symptoms, consider a DBT skills workbook. For OCD, Brain Lock.

2. Free support groups: Alcoholics Anonymous is neither as great as the proponents say nor as terrible as the detractors say; for a balanced look, see here. There are countless different spinoffs for non-religious people or people with various demographic characteristics or different drugs. But there are also groups for gambling addiction, sex addiction, and food addiction (including eating disorders). There’s a list of anxiety and depression support groups here. Groups for conditions like social anxiety can be especially helpful since going to the group is itself a form of exposure therapy.

3. Therapy startups: These are companies like BetterHelp and TalkSpace which offer remote therapy for something like $50/week. I was previously more bullish on these; more recently, it looks like they have stopped offering free videochat with a subscription. That means you may be limited to texting your therapist about very specific things you are doing that day, which isn’t really therapy. And some awful thinkpiece sites that always hate everything are also skeptical. I am interested in hearing experiences from anyone who has used these sites. Until then, consider them use-at-your-own-risk.

III. Supplement Analogues

This section is for people who can no longer afford to see a doctor to get their prescription medication. It discusses what supplements are most similar to prescription medications. This is not an endorsement of these substitutions as exactly as good as the medications they are replacing, a recommendation to switch even if you can still get the original medication, or a guarantee that you won’t go into withdrawal if you switch to these. They’re just better than nothing. Make sure to get these from a trusted supplier. I trust this site, but do your own investigation.

This doesn’t include detailed description of doses, side effects, or interactions; you will have to look these up yourself. These are all either legal, or in a gray area of “probably legal” consistent with them being very widely used without punishment. I am not including illegal options, even though some of them are clearly stronger than these – but you can probably find them if you search.

1. Similar to SSRIs: 5-HTP. This is a serotonin precursor that can serve some of the same roles that selective serotonin reuptake inhibitors do, though this is still controversial and it is probably not as strong. Cochrane Review thinks that “evidence does suggest these substances are better than placebo at alleviating depression”. This may plausibly help with SSRI withdrawal, though not as much as going back on an SSRI. It can be dangerous if you are taking any other serotonergic medication, so check with the doctor prescribing it first. Cost is about $10/month. Definitely legal.

2. Similar to antidepressants in general: Tianeptine. This is a European antidepressant which is unregulated in the US, making it the only way I know to get an regulatory-agency-approved antidepressant without a prescription. Look up the difference between the sodium and the sulfate versions before you buy. Generally safe at the standard dose; higher doses carry a risk of addiction. Cost is about $20/month. Probably legal, widely used without legal challenges.

3. Similar to stimulants: Adrafinil. This is the prodrug of modafinil, a stimulant-ish medication widely used off-label for ADHD. Modafinil itself is Schedule IV controlled (though widely available online); adrafinil is unscheduled and also widely available. Look up the debate over liver safety before you use. Cost is about $30/month. Probably legal, widely used without legal challenges.

4. Similar to anxiety medications: GABA and picamilon. GABA is an endogenous inhibitory neurotransmitter, but it has questionable ability to cross the blood-brain barrier when taken orally (though see here for counterargument). Picamilon is the same neurotransmittor attached to a niacin molecule that helps it cross the BBB more readily. Both are sold as supplements. The evidence base is weak, and this is the entry on this list I am most skeptical of. Use at your own risk (of it not working; it’s probably pretty safe). Neither of these is as strong as a benzodiazepine and these will not significantly relieve acute benzodiazepine withdrawal. Cost is about $30/month. GABA is definitely legal. Picamilon is possibly legal; the FDA has tried to stop companies from selling it as a dietary supplement, but does not seem to be challenging users.

You can find a discussion of other supplements for depression at Part IV here and for anxiety at Part IV here. You can find a discussion of ways that supplements can play a very minor role in helping with psychosis in the second to last paragraph of Part 12 here, but please don’t rely on this. I no longer 100% endorse everything in those lists.

If you know other safe and legal ways to save money on psychiatric care, please mention them in the comments and I’ll add them as they come up.

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105 Responses to Mental Health On A Budget

  1. sandorzoo says:

    Thank you Scott. You are doing the world, or at least the American part of it, a great service here.

  2. Rana Dexsin says:

    As a pointed anecdote, only: I recently tried BetterHelp on someone’s recommendation, and they make some strange promises in their FAQ regarding not having to identify yourself. Suffice it to say that what this actually means in practice is a lot weaker than what the FAQ implies; I don’t think the end result is worse than traditional therapy in terms of how much information you have to provide, but don’t go in thinking you can actually stay pseudonymous with your matched therapist. The way this was handled felt deceptive enough to cause me to lose all trust in them, so I never got into the actual therapy experience proper. (I feel like there were some other dark-pattern things going on too, but I don’t remember them specifically enough to say.)

    • Sea says:

      I have used BetterHelp with very good results. I suppose it depends on which therapist you are assigned, but you can change therapists as many times as you need with the click of a button.

      Furthermore, they provide financial aid to anyone who claims to need it: you just fill in a questionnaire where you state your income, how many dependents you have, whether you have a job, etc, and they give you a discount based on that information. No need to prove any of your statements. For example, a friend of mine was a student with no income, and they asked him for about 13$ per week, irrc. In my particular case (reasonably well paying job, but not amazing), they asked for ~30$/week. This covers one 1h session per week, together with unlimited texting with your therapist.

      I don’t know about the promises on the FAQ, since I was not particularly worried about not identifying myself to begin with.

    • tree says:

      FWIW, I have used BetterHelp with very good results. I suppose it depends on which therapist you are assigned, but you can change therapists as many times as you need with the click of a button.

      Furthermore, they provide financial aid to anyone who claims to need it: you just fill in a questionnaire where you state your income, how many dependents you have, whether you have a job, etc, and they give you a discount based on that information. No need to prove any of your statements. For example, a friend of mine was a student with no income, and they asked him for about 13$ per week, irrc. In my particular case (reasonably well paying job, but not amazing), they asked for ~30$/week. This covers one 1h session per week, together with unlimited texting with your therapist.

      I don’t know about the promises on the FAQ, since I was not particularly worried about not identifying myself to begin with.

  3. philipkd says:

    Not surprisingly, this “mental health on a budget” post looks like a good triage/first-pass/starting-point. If the mental health journey is at all intimidating, why not prescribe blog-therapy and just read this post?

  4. userfriendlyyy says:

    If you do have Insurance, even high deductable, you are guaranteed to have a free yearly physical. If you have a relationship with your GP and say “I’ve been really depressed/anxious lately and I’ve done a lot of research on the internet and I’d like to try ______, but I can’t afford to see a shrink right now.” They will most likly help you, especially if _____ isn’t a controlled substance.

    • Thomas Bridgeland says:

      Unfortunately, if during the ‘free’ yearly physical, you mention any health issue, the ‘free’ portion is null and it becomes a regular office visit. Copays and other charges then apply. I state this both from personal experience of myself, children and spouse in recent years, and also from my 5 years working in medical claims for an insurance company. Much depends on how the doctor chooses to present the claim. Some will freely give advice and still bill as a routine wellness visit, but many will bill as a ‘sick’ visit.

      • raj says:

        Wow, I’d never see that doctor again and I’d probably go out of my way to leave them poor reviews online. I’ve gotten 3 out of 3 separate annual physicals with requests for medicine from different doctors, no issue.

  5. Matthias says:

    Stimulants: nicotine patches are safe and legal.

    (Don’t confuse nicotine from patches with inhaling burning tabacco. The former is safe, the latter looks cool.)

    See gwern for details.

    • The Nybbler says:

      Nicotine is still addictive in patch form. Has anyone compared how addictive nicotine is compared to tobacco as a whole?

      • rlms says:

        I believe essentially all of tobacco’s addictiveness comes from nicotine (but very little of its harmfulness does).

        • Lambert says:

          Not all of it, but some.
          MAOIs (or similar chemicals) in tobacco potentiate nicotine addiction.

    • Antistotle says:

      Nicotine is /not/ safe. It is toxic (at least one source claims the LD50 is less than arsenic or strychnine), it constricts blood vessels, so prolonged usage can harm cartilage (this is a problem with smoking–the carbon monoxide + vasoconstriction damages spinal cartilage). There are some indications that nicotine alone can cause/promote certain cancers (I don’t think this risk rises to the level of “unsafe”, but in conjunction with the other risks, it adds up).

      And it’s addictive.

      Not saying don’t do it, not saying it should be banned or (more heavily) regulated, but head up, eyes open, know the risks and don’t pretend it’s something it’s not.

      • The Nybbler says:

        at least one source claims the LD50 is less than arsenic or strychnine

        Absolute LD50 isn’t particularly important given precise dosing; ratio between therapeutic dose and lethal dose is.

        That it constricts blood vessels goes along with being a stimulant; that’s a common property of stimulants.

      • anon1 says:

        > LD50

        Nicotine is a strong neurotoxin, but not in a way that’s related to the longer-term issues and not in a way that’s risky unless you do something really stupid, like eating cigarettes or pouring concentrated e-cig liquid on your skin. Otherwise the nausea, vomiting, dizziness, etc. are more than enough feedback to prevent dangerous overdose.

        Agreed on the rest of the comment.

      • blarglesworth says:

        The LD50 is considerably higher than the 30-60 mg or 0.5-1.0 mg/kg commonly quoted, based on reports of nicotine ingestion from e-liquids. The actual lethal dose is somewhere well above 500 mg.

        But it’s still highly addictive, and really not particularly helpful for any psychological problems or even as a caffeine-strength stimulant. At least in my experience as a low-energy depressive who picked up vaping a year ago and can’t quit.

      • Thomas Bridgeland says:

        Generally agree with the above.
        One advantage of nicotine is that it is easily grown in your back yard, and easily processed into a pleasant chew form.

  6. wheeler says:

    What’s people’s take on the safety of the Indian pharmacies (such as good-pills.com) that will supply prescription medication without a prescription?

    • Garrett says:

      Follow-up: Are there any good online pharmacies (regardless of national origin) which will supply prescription medication without a prescription?

      • Eric Rall says:

        I’ve used Inhouse Pharmacy several times in the past, mostly for pet medications. They’ve been around for ages, seem to have a good reputation, and I’ve never had problems with them. Most of their drugs seem to be sourced from New Zealand.

        They carry several common antidepressants and anti-anxiety drugs, among other things, but they do not carry controlled substances (adderall, modafinil, etc). They require you to certify that you have a valid prescription, but this is strictly on the honor system.

      • bimbolot says:

        Modafinil, Armodafinil, Memantine: https://nootropicsjet.com

    • I’ve used AllDayChemist without issue.

    • Edward Scizorhands says:

      I was forced to resort to one of these once when doctors had fallen through on something that has withdrawal symptoms. I got a bunch of sales calls to my phone for a few years (back when spam phone calls weren’t that common) for everything you see advertising in email spam.

    • rm0 says:

      The folks over at /r/TransDIY say alldaychemist, inhousepharmacy, and QHI are all good. I’ve only used IHP, and then only once, but it went well. You can search the subreddit for more people’s experiences.

      Oh and this may or may not be related to that, but I noticed packages in my mail looked like they had been opened a few times after ordering from them.

  7. terrafirmer says:

    Persons living near universities with clinical psychology programs may be able to access free or very low cost individual or group therapy in program clinics, as well as psychoeducational testing for ADHD, etc, as offered.

  8. raremask says:

    Are there any therapists who offer remote phone/skype sessions who you would recommend? I’ve had a really rough year and have been looking for that, but haven’t found anyone yet.

    • cuke says:

      There are a lot of therapists who do phone/video sessions but generally in the U.S. therapists are only licensed in the states in which they practice, or maybe an adjacent state or two if they live near the state line. This will change hopefully in a decade or so, but for now, a therapist can’t ethically treat a client who lives outside of a state where they are licensed to practice.

      The other piece is that distance therapy is not generally covered by insurance, so you’d likely have to pay out-of-pocket for it. If you’re willing to pay out-of-pocket, you can look at the Psychology Today listings for therapists in your area and reach out to ones who look appealing to you, and see who is willing to do therapy by phone or video.

      • Confusion says:

        a therapist can’t ethically treat a client who lives outside of a state where they are licensed to practice

        Do you mean legally instead of ethically or do you really feel it is unethical to treat a client just because they live a few miles the wrong way? If so, I’m curious as to your arguments.

        • andreamedaris says:

          I can’t speak to what they meant, but it is mostly illegal? A therapist can’t use a protected term to market themselves (psychologist, mental health counselor in some places), can’t accept insurance, and the legal protections of confidentiality might not apply if practicing in a state where they’re unlicensed. I THINK (not a lawyer) one could legally offer life coaching or some analogue without a license but it would be ethically shady given that they are probably marketing themselves as whatever they’re licensed as within their home state.

  9. fr8train_ssc says:

    Under Therapy, I don’t know what your experience has been with such programs, but if one lives in a town/city with a good university system, one could benefit from Therapy from grads/psychiatrists-in-training?

  10. Garrett says:

    Book suggestion for people with ADHD-like conditions: Driven To Distraction.

    • mark_o says:

      I’d second this, and add that A User’s Guide To The Brain by John Ratey, one of the coauthors, was pretty helpful for me in thinking about my own thinking generally. (I do wonder if the state of neuroscience might have moved on somewhat in the ~17 years since it was published. I found it compelling when I read it a couple of years ago, but I’d love to hear what people knowledgable about brain things thought of it.)

  11. SamChevre says:

    An additional suggestion: be sure to see if Wal-Mart has your medication on their $4 prescription list. Generic citalopram costs $20-$30 in many pharmacies, but $4 at Wal-Mart and some of the other big-box stores with similar programs.

    • Eric Rall says:

      Relatedly, many pharmacies have on-site clinics with an NP or PA who can write prescriptions, mostly for treating routine minor illnesses (e.g. antibiotics for an ear infection) or short-term extensions of existing courses of treatment (e.g. renewing an expired prescription for a maintenance medication). There’s a bit cheaper than going to a regular doctor’s office without insurance or if you’re under your deductable. Here’s CVS’s service and price list. Walgreens has similar clinics, and I think Wal-Mart does as well.

  12. Berna says:

    Book suggestion for people with alcohol problems: Allen Carr’s Easy Way to Control Alcohol. Worked like a charm for me.

    • Rusty says:

      I used his stop smoking book and it ended my 20 year addiction overnight. I read the alcohol one out of curiosity and was slightly alarmed to find I had lost the urge to drink even socially. I don’t really understand how he does it.

  13. Jaskologist says:

    I feel like I would be remiss if I didn’t add “go to church lol” to the list.

    • __phoenix13 says:

      Likely merely a proxy for having some functioning social community in the first place.

      Atomized modernity is clearly conducive to depression, but ‘hey just believe these arbitrary things and we’ll try not to let you get too lonely’ is perhaps not an ideal solution.

      • Edward Scizorhands says:

        There are lots of religious groups where you can go through the motions and everyone will be perfectly happy with you despite you not believing. You won’t be called to testify as to your faith, either formally or socially.

        • Aapje says:

          You also have borderline atheist Christians, where it is perfectly acceptable to define God as nature or such.

    • ilikekittycat says:

      I feel like I would be remiss if I didn’t say, be extremely careful about going down this road, because nothing will exacerbate your problems like finding out how quickly they will give up on you when they discover a way in which you’re fundamentally different from them that they don’t want to deal with.

    • rlms says:

      I don’t think those studies are very convincing. One would expect church attendees to be healthier (both mentally and physically) than non-attendees, because really ill people are stuck at home or in hospitals (and moderately ill people are more inclined to stay at home than go to church). Also note that the second study claims that Mormons have major depression at twice the rate of the general population! (I don’t know how relevant that is to the question of the effects of church attendance because the study doesn’t seem to have data about church attendance of the different religious groups).

  14. johan_larson says:

    None of this is medical advice; use at your own risk.

    I have to wonder how much good a disclaimer like this actually does, in a post that makes specific recommendations about pharmaceuticals and therapeutic methods. If that’s all it takes to get regulatory or legal cover, the regulators and lawyers are awfully literal-minded.

  15. tst says:

    Moderate intensity exercise (running 3-5 miles or ultimate frisbee for me, even just a couple times per week) works pretty well to manage my (relatively mild) depression–about on par with low-dose SSRIs.

    More significantly, it was a miracle cure for moderate-to-severe SNRI (Effexor) withdrawal. Basically the flood of exercise-induced endorphins completely swamped the withdrawal symptoms.

    Not for everyone for a bunch of reasons, but has the virtue of being approximately free.

    • j1000000 says:

      Yeah Scott talks about lifestyle help for depression in other places, like in part 3 of: http://slatestarcodex.com/2014/06/16/things-that-sometimes-help-if-youre-depressed/

      He mentions, specifically: Trying therapy on yourself, better sleep, getting exercise, light therapy, and quitting drugs and alcohol, and also links to a CureTogether site that has plenty of other things people found helpful like spending time with friends/pets

    • cuke says:

      I second this. And the research does too.

      And I’ve also heard from folks who significantly reduced their Effexor withdrawal through lots of aerobic exercise (also water and B vitamins).

  16. David Shaffer says:

    Can you go into more detail on adrafinil safety? Using it I get mild pain around the liver and kidneys, which doesn’t match any side effects I’ve been able to find discussed online. Yes, it’s hepatotoxic, but from the description, that’s a problem for long term use, not something that would cause pain on day one.

    • sunnydestroy says:

      You should keep in mind that the liver toxicity can be dependent on how sensitive your liver is, previous injuries to your liver, other medications, alcohol use, water consumption, certain foods, etc. Taking it often will also build up the damage more quickly. You should probably get your liver enzyme levels checked just in case.

      One thing you can try is taking milk thistle extract after since it’s a good liver therapeutic supplement. It promotes liver protein synthesis after the injurious activity.

      • David Shaffer says:

        Thanks for the response! I have no previous liver injuries, am not taking other medications, and have gone off alcohol entirely for the duration of the adrafinil experiment (previous consumption was 2-3 drinks roughly once/month). Milk thistle I can take a look at.

        What confuses me was that the pain started day one. Everything I could find about adrafinil toxicity suggested that the effect was due to the liver gradually ramping up production of the enzymes needed to metabolize adrafinil, until they reached levels that could damage the organ as well. Obviously not good over a long period of time, but is it even possible for that to cause immediate pain?

        • Bond says:

          I had a similar side effect once or twice, along with headaches, and it seemed to match up with some folks’ reaction to -afinil as a diuretic – which could result in quick kidney pain. After a couple weeks, I made some guidelines for myself and haven’t had any sort of side effects since:

          – No alcohol or tylenol within ~6 hrs
          – Plenty of water
          – Take with Lecithin (choline) and an ibuprofen
          – Low doses (100-300mg), never more than 2-3 days in a row

          Hope that helps!

          • David Shaffer says:

            Thanks! Already doing the no alcohol/tylenol. I’ll try drinking more water and cutting the dose. Choline is worth taking a look at; would ibuprofen reduce damage? I was under the impression it was mostly just a painkiller. Of course less pain is good, but I’m mostly trying to avoid damage; the pain is mild, but if it leads to liver damage that’s obviously another story entirely!

            Also, a friend told me he gets the same effects with modafinil, which surprised me even more since modafinil is supposed to be pretty liver-safe. Any thoughts on that?

          • Bond says:

            Choline and an ibuprofen really toned down the occasional headaches for me. Neither should do much for the liver, unfortunately.

            But from what you’re describing (liver or kidney pains, too fast for any liver mechanism) I’d start thinking about whether it’s kidneys – modafinil would have the same diuretic effect as adrafanil there, and the cure – lower dose, more water – is easy to test.

        • Squirrel of Doom says:

          I’m probably not helping, but this sounds a lot like textbook psychosomatic pain.

          You take a new pill, you’re a bit worried about how it will affect certain organs, and the next day you feel a bit of pain around those same organs.

          Personally, I usually feel a bit of pain in the proper location when reading about some exotic ailment I imagine I could have.

          • David Shaffer says:

            Is there a good way to test psychosomatic vs real pain? I suspected placebo effect too for the first couple of days, but it was sufficiently persistent that I think it’s a real effect.

  17. maximiliantiger says:

    (Actually) Asking for a friend: any recommendations on getting cheaper vyvanse? My friend spends $300 a month on it.

    – She’s tried other medications but didn’t have success switching to adderall
    – Goodrx puts vyvanse at $300 or more when I checked it. Switching to 90 day supplies just triples the price. But upping the dosage does keep the same price so that looks like a good option
    – Canadapharmacy.com doesn’t have vyvanse
    – She lives in SF with a good salary, so probably doesn’t qualify for the assistance programs
    – no idea why her insurance isn’t more helpful in paying for vyvanse

    I think she also pays out the nose to see a psychiatrist in SF (apparently there’s an undersupply here?), just to get the prescription in the first place, though I’m not sure if that’s as easily solvable

  18. Douglas Knight says:

    I’ve heard that pharmacists will split pills for you. Have you ever tried writing that on the prescription?

  19. belvarine says:

    Not to nitpick but (aside from you mentioning exercise previously on reviews of antidepressants) is there a reason you didn’t include exercise on here? The effects on mental health appear to be profound:

    https://en.wikipedia.org/wiki/Neurobiological_effects_of_physical_exercise

    I know exercise isn’t always cheap (in terms of time, energy, and/or finances) but most YMCAs offer financial assistance and a pair of $5-10 sneakers from Payless will last for months. If you’re absolutely dirt poor and hate going outside, stair climbing is an excellent low impact, high cardio exercise that builds your core muscles. I actually have to cross train on a stairmaster often, otherwise distance running (my favorite) is a minefield of injuries.

    The threshold for most of these studies is 30 minutes of moderate exercise (60-70% max heart rate, which is typically enough to get your heart pumping while just barely breaking a sweat) at least 5 days per week. You can watch TV or listen to podcasts/news while walking briskly walking or riding an exercise bike and reap enormous benefits. I won’t bother listing them here. The wiki article is very long.

    Acute effects tend to last up to 2 hours, long term effects appear to take a few weeks to kick in. If you stop exercising completely, it takes around 3-4 weeks of sedentary activity to return to baseline. In my personal experience, the really profound effects (improved memory, better spatial processing, sociability, mood, executive function) take about 5-6 months to kick in.

    • Antistotle says:

      Exercise is *hella* cheap–You don’t need a gym, you don’t need running shoes, you need about 20 square feet of relatively empty space.

      Do rounds of these for 1/2 hour every other day until you stop feeling sore the next day, increasing the “reps” per “set” as you can. Move right from one exercise to the next without stopping any longer than ABSOLUTELY necessary:
      10 x Pushups–start off with “regular” pushups, but advance into wide, regular and close grip.
      10 x Lunges (each side) or “air squats” –lots of these to “play” with.
      30 second Planks or 10 leg lifts.
      30 seconds back bridge or 10 hip raises (one is a “static” version of the other).
      10 “side straddle hops”, or if you’re old school “jumping jacks”.
      Then rest by stretching for 2 minutes.

      When you can finish the 1/2 hour without wondering if death is a better option THEN you start in on the burpees. Burpees suck. After 5 or 10 burpees you no longer wonder is death is a better option. As long as it’s not death by Burpees. They should really call them Vurpees.

      You can do these in a pair of shorts. Well, a pair of shorts and sports bra for some folks.

      These won’t turn you into Arnold S, but will raise your heart rate and work your muscles.

      A moderately healthy person will hit the limit of this approach relatively quickly, but when you can get 100 pushups, 100 squats/lunges a couple minutes of planks and bridges done in a half hour you’re *so* far ahead of the average person physically it’s not funny.

      • FLWAB says:

        Being a cheapskate I was attracted to this kind of exercise. Sadly, though exercise makes me feel better, I’ve never been able to make an exercise routine stick. Push-ups have been an especially sore subject for me, as I’ve never been able to do more than three (at my best) in a row before taking a break. This always made me feel like a failure as a male, and now that I think about it likely dredged up shameful memories of being unable to perform push ups or pull ups when required in PE classes. Ultimately I stop exercising for a variety of excuses, but mostly because of feelings of futility (also, it’s hard to work out intensively enough to get anti-depressant benefits when you can’t do the most basic exercise n the routine).

        I know it takes time to build up strength and make progress, but I never manage to stick with it long enough to stop feeling like a failure. Lately I’ve decided to try working out through manual labor and that’s been working a lot better. The fact that something tangible has been accomplished after my workout (like a pile of cinder-blocks has been set up for a garden, or the turf has been removed for the garden, or large bags of soil have been spread on the garden) seems to bypass the feelings of futility that normally sabotage my workouts. Major problem: I’m running out of labor intensive projects to work on.

        • Antistotle says:

          > Push-ups have been an especially sore subject for me,

          I f*ing hate them. No, really. But I do them a couple times a week. Part of that is that I do a martial art where we do them as a warmup, and I will NOT not meet the standards. For the Scholar rank you have to be able to do 50 pushups, 50 air squats, and 50 situps *THEN* do the rest of the test. I’m nowhere near that rank, but I’m getting close on the pushups.

          When I wasn’t in that art I would do bench presses instead, but I can afford a gym.

          > as I’ve never been able to do more than three (at my best) in a row
          > before taking a break.

          Do them on stairs. Pick the lowest stair on which you can do 10, then work up to 20. Also, until you can do 10 at a time do them throughout the day. If you can only do three, do three every hour all day long.

          And eat more protein. Lots more protein.

          > Major problem: I’m running out of labor intensive projects to work on.

          If you live in the Denver Area I’d be willing to assist you in that. Won’t even charge you very much 🙂

          More seriously though, depending on where you live find some older/disabled folks who might need help. Find 5 people who need their lawn mowed and can’t really do it anymore or afford to pay someone and there’s a weeks worth of work outs out in the weather and doing some good. Well, at least April through October (depending on where you live). The other months shovel their driveways.

          Seriously though, there’s really no substitute for discipline.

          However there is a way to require *less* discipline. You simply find something you hate or like less that accomplishes the same goal. My goals include being able to do 50 pushups, but I don’t need to do pushups every day to do that, so some days I do bench presses and overhead presses, some days I do dips, rows and pullups, I try to swim hard for 30 minutes a couple times a week–living across the street from a gym helps.

          But I can do that because I can afford a gym.

        • Reasoner says:

          Sounds like you need shovelglove.

          • knockknock says:

            That looks seriously interesting. I love how he comes up with 14 minutes for the workout instead of 15. The 1970s Pittsburgh Pirate sluggers used to scare opposing pitchers by waving around a sledgehammer and other hardware in the on-deck circle.

      • knockknock says:

        Heck, I just started bending, squatting, lifting and stretching with a pair of handweights. Do the stairs a few times and give the dog a bonus hike (everything here is uphill both ways!) and I’m set. And I’m 63.

        After just a few months the effects — especially the mood effects — were striking. If you’re sleeping better and getting that T-count up a little, a lot of things fall into place. Pick out an album or lecture to listen to so it’s a treat instead of a chore

        • Antistotle says:

          I have a 70 pound New Mexican High Desert Garbage Hound. We do 2 miles almost every morning, and if I have time 4-5 miles on Sunday.

          And yes, every little bit helps.

          I don’t listen to anything, I just walk with my dog. He’s awesome. Except when he wants to get in a fight. Well, and when he won’t let me sleep another 10 minutes because WALK NOW WALK NOW.

  20. Squirrel of Doom says:

    Last I checked, I couldn’t find any reasonable Adrafinil source online.

  21. MoebiusStreet says:

    In “4. Pharma company patient assistance programs” you mention that needy patients can apply for discounts from the manufacturers. Actually, there are plenty of programs that are *not* needs-based, and seem to be simply a marketing program potentially open to anyone.

    I’m actually enrolled in two of these (not for mental health related stuff, but I don’t see how that makes a difference). In both of these cases, there’s a requirement that you must be on a private insurance plan. But given that, they cover the entirety of what your insurance does not cover.

    For example, I get infusions of Entyvio for Crohn’s disease. This has a price tag of about $17000 every 8 weeks (although in fact the billing to the insurance is only something like $4000). And because it’s a new drug, typical insurance leaves a very large co-pay, and of course there’s your deductible. But with this assistance program, which you of course have to submit to the provider (the pharmacy or in my case the infusion center), I wind up getting billed $0.

  22. __phoenix13 says:

    I agree with most of these recommendations, based on my own past reading and direct personal experience with many of them.

    I am surprised, however, to again see no mention of sarcosine in the supplements section.

    Sarcosine outperformed citalopram in a head-to-head human clinical study. It produced no significant side effects, a far higher rate of remission, and lower remission onset latency i.e. less time spent waiting for improvement.

    Sarcosine has also demonstrated human efficacy in the treatment of the negative symptoms of schizophrenia, which bear a strong resemblance to some aspects of major depression.

    A few articles on the subject:

    http://www.mind-and-brain-blog.de/en/1628/is-the-glycine-transporter-inhibitor-sarcosine-also-effective-in-depression/

    http://www.thedoctorwillseeyounow.com/content/depression/art4215.html

    https://www.medscape.com/viewarticle/815027

    Here is the Examine.com literature summary:

    https://examine.com/supplements/sarcosine/

    • christmansm says:

      The study in question has some pretty serious red flags. The biggest is that citalopram shows no remission at 4 weeks and 1/20 patients at 6 weeks. That’s not at all consistent with typical RCTs where even sucrose gets a 25-35% remission rate in 4-6 weeks, with antidepressant X maybe 10-20 points ahead.

  23. Michael Arc says:

    If exercise is in, how about taking care of a neighborhood pet? Where does it all end?

    • Antistotle says:

      I believe (which means I have little or no evidence for it) that a lot of people would benefit from having a medium sized dog in their life. You have someone who pretty much moves you unconditionally, but at the same time needs certain things from you that require a bit of discipline (feed them, water them) and that you also benefit from (say 20 minute walk 2x a day), which would be even better if you could take that walk some place where there is a lot of natural green (park/open space etc.)

      • knockknock says:

        Dogs love a structured routine, and providing it is very healthy for the human (along with the fun, affection, exercise etc). Problem is, this is NOT a low-budget strategy even with just routine vet visits.

        • Antistotle says:

          Depends on how low is low. There are lots of fairly poor folks with dogs. Maybe they don’t take them to the vet enough, but the dogs get by.

          Oh, and you could always work with a rescue that is trying to place an older dog, or a “permanent foster”.

          Part of the goal (I would suspect) is to get your mind healthier so you can find better work.

      • Douglas Knight says:

        moves you unconditionally

        great pun!

  24. upgradetospace says:

    I wanted to post my experience with 5-HTP. Over the last few months I had been severely depressed and extremely anxious. I’ve always been an anxious person, but when I get depressed it gets worse and I have a hard time keeping it in check. I also seem to plunge back into my disordered eating patterns during depression, probably related to the higher anxiety. I came across 5-HTP on accident; I ordered a fat burning stack from a supplement company. One of the supplements has 5-HTP. Taking it I noticed an immediate different in my mood and thought patterns. I wasn’t spiraling, and anxiety about my body and food mostly went away. My partner noticed a big difference too, and that’s when he asked the maker of the supplement what ingredient was responsible. Now I take 200 mg of 5-HTP everyday and 1000 mg of L-Tyrosine (This is so I don’t build a tolerance to 5-HTP). I can’t take the fat burner all the time because it does have other stimulants in it that aren’t meant for long term use. It’s been 1.5 months on the 5-HTP and so far it has worked well for me. Even in times of stress I am able to cope better because I can stop my spiraling thoughts. I do know some other people who have tried 5-HTP, but they said it made them feel nauseous all the time. It doesn’t do this to me, but to be honest if it did I would learn to live with it because it’s better than my alternative.

    • Glenn says:

      Huh, I actually perked up when you mentioned nausea, because it’s well-known that there are 5-HT3 receptors that induce nausea; so that’s a side effect that suggests the 5-HTP is actually being properly metabolized into serotonin in the brain.

      It seems, in my experience, that propensity for serotonin-induced nausea seems to vary a lot across individuals; the variation is easy to observe in people’s reaction to certain types of recreational drugs. (I guess it holds for 5-HTP also?) I’m suspicious that there’s some genetic component related to people’s 5-HT3 receptors, but I’m really speculating wildly and have no basis for it.

      • Glenn says:

        (Ok, I realized that the end of the first paragraph is clearly wrong — it’s a sign that suggests that there is serotonin in the _gut_. That’s not quite as compelling.)

    • blarglesworth says:

      I can confirm that 5-HTP has serotonergic effects. Back when I was abusing DXM/cough medicine, which is known to be a strong serotonin releasing agent, I was coming down off a one-bottle dose and decided to take a dose of 5-HTP. I spent the next three hours in a state of mild serotonin syndrome. My temperature increased slightly (it reached 99.6 F from normal state of about 98.2), hyperreflexia and muscle spasms occurred, and I felt a powerful sense of anxiety and dread. It was a not-so-fun but still interesting experience.

  25. Nate the Albatross says:

    For my wife’s depression meds, but not mine, the cheapest option was buying them at Costco. She got one month for $10, and paid out of pocket so there was no copay. YMMV. Of course if you are poor you probably don’t have a Costco membership… but for certain expensive medications the membership might be worth it.

    I can speak to the 90 day thing. Not only is it cheaper but also you end up with fewer prescription renewals which can also cost money.

    • Eric Rall says:

      Depending on where you live, you might not need a Costco membership to use their pharmacy, since many states require pharmacies to be open to the public. I’m not sure which states, so you may need to call up the store and ask (and also ask the procedure to get in to the pharmacy desk if you need to go through the regular shop floor to get to it).

      • knockknock says:

        The regular annual membership is $60 so you could easily save much more through their pharmacy bargains even if you don’t need, like, a 40-pound jug of laundry detergent or 5-pound block of Jarlsberg. (And if your Costco has a gas station you could save a buck or two each fill-up too)

        I read at MarketWatch that Sam’s Club has pharmacy discounts too but you need their higher level membership, about $100.

      • Douglas Knight says:

        The Sam’s Club pharmacy seems to be open the public. Costco only where required by state law, but I don’t know which states.

    • SamChevre says:

      Costco’s list overlaps 90% or so with Walmart’s list. But yes, the big-box generics vary by store–it’s well worth checking if any of them has your medication.

    • bean says:

      I bought a Costco membership to get access to their mail-order pharmacy for modafinil, even though there isn’t a Costco in my city. It saved me money on the first 90-day supply alone relative to buying it locally.

  26. amaranth says:

    ime tianeptine is more like a stimulant than anything – except it increases spoon-energy directly while leaving animal-energy mostly alone? but like any stimulant, it really cuts into spiritual awareness, making higher-consciously perceived time fly by much more rapidly 🙁

    so i use it for difficult / tedious work, but not for creative work

  27. Edge of Gravity says:

    7cups.com has an online text therapy option for US$150/month, with therapists replying at least once a weekday. They have an easy-cancelation 3-day money-back policy. Apparently enough people use it regularly to keep this startup afloat.

    What this site is more famous for is anonymous volunteer active listeners who spend their time hearing you out. Like everywhere, your mileage may vary. Some listeners can turn your life around within a single hour just by listening, reflecting, empathizing and asking the questions you have never thought of, others just want to role-play their sexual fantasies (against the site rules, but not easy to police). Most are somewhere in between. Listeners, group support rooms, forums and scheduled discussions are all free and they do not currently verify your email address upon sign-up, so the site is easy to try. And feel free to reply with how it went for you.

  28. Carl Milsted says:

    L-theanine is supposed to cross the blood brain barrier and increase GABA within. Might be useful for those who cannot easily stop stray thoughts. I use it sometimes to improve concentration. It does so without creating the jitters of caffeine.

    For what it’s worth, L-Tryptophan is back on the market. I have no idea whether it is better or worse than 5HTP, or if it helps medical depression. I do take it now and again to induce sleep. Tends to produce a lot of dreams for me. I don’t like the effect if I take it too often.

    Decades ago I read in the Life Extension books that you can get tryptophan across the blood brain barrier by simply eating a high starch very low protein meal. (Other amino acids compete to get across the barrier.) This might explain why many meditative schools advocate a vegan carbo-mush diet. I do find the trick very helpful for better sleep. These days I prefer to eat my heavy meat meal earlier in the day. I have no idea whether this helps with medical depression. (Unless that depression is caused by insomnia, in which case this trick could be very helpful.)

  29. Professor Sophist says:

    Saffron is a GABA agonist that is effective for anxiety, insomnia, and depression; is available readily on Amazon for less than $10 per gram with an effective does of 100 milligrams; and has some solid science behind it. See, for example, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599112/ Have tried this personally and found it less effective than a benzodiazapine or z drug but more effective than both meletonin alone or meletonin plus gaba/valarian/skullcap sleep aid. Avoid if you allergic to saffron. Legal.

    Raw cacao is an amazing delivery system of phenethylamine, good for a temporary delivery of euphoria and sense of well being. Also has lots of magnesium which is good. Potentially beneficial as a pharmaceutical aid during therapy, whether self administered or professional, in a way similar to MDMA. Have tried this personally, found it thoroughly enjoyable and an effective stimulant, comparably to a mild dose of amphetamine but much better. Don’t have any research on this per se. Avoid if you are sensitive to caffeine or get migraines easily. Legal.

    Context: I’m on a complex of pharmaceuticals, some with prescriptions (including an SSRI) and others not, not all of which are legal. I have personal experiences with a fairly wide spectrum of substances. I’m including these two because they are legal, accessible, and quite effective both from personal experience and from having recommended them to others who have found benefit.

    • Reasoner says:

      Be careful with saffron, it can be toxic if you take too much.

      • Professor Sophist says:

        Correct but; the toxic dose for saffron is ~5gram while an effective does is, at most, 200mg. Take 25x the effective dose of almost any drug and there will be problems. To my knowledge there have not been many studies done on long term use and so the accumulated effects of prolonged use could be problematic. See however, for example, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5339650/ for decent analysis of harms.

  30. Craig says:

    For an experience more like therapy than a support group, for those who are not in too bad a shape, these work by trading listening with a partner.

    I do recommend this one, and it makes a good supplement to regular therapy.
    http://www.focusing.org

    This one has a reputation as a cult, but your results may vary.
    https://www.rc.org

    There may be others to be found.

  31. blarglesworth says:

    Phenibut is far more effective than and as legal as picamilon. The downside is benzodiazepine-like withdrawal should you decide to take it a majority of all days, or more than about four days in a row, or in doses of 2 grams or more per day. Benzo withdrawal really, really, REALLY sucks, so don’t play fast and loose with it. Occasional use, though, has minimal risks. It lasts fully 12-16 hours but doesn’t kick in for 2-3; be patient and do not redose.

    Moclobemide, a reversible MAOI, has cleared the FDA-equivalent of all other Western countries but the US, and can be purchased in the same manner as tianeptine. It’s far safer than irreversible MAOIs (e.g. Nardil aka phenelzine, and Parnate aka tranylcypromine) – there is no need to avoid tyramine-containing foods like cheese or beer. It is still an MAOI, though, so do not ever combine it with e.g. any other antidepressant, or with decongestants like pseudoephedrine or cough medicine (dextromethorphan). Look up a list of things MAOIs interact with, and if anything you take is on there, don’t take it. But if not, it could be worth a shot.

    Kratom is still legal in like 44 states and is widely available online. It has mild opioid-like effects which are helpful for recovering opioid addicts, but in my experience it has significant stimulant and antidepressant effects as well. When I take it, it causes me to be interested in what I am doing, not just awake and more focused like caffeine or even modafinil. It may be worth a shot if your depression involves fatigue and apathy as its primary symptoms, or of course if you have an opioid problem. Caveats are that it is at least mildly addictive, may be criminalized at any time, and may raise your blood pressure (it elevates mine by about 20/10).

  32. anon1 says:

    Some plausible things I found while skimming https://en.wikipedia.org/wiki/List_of_herbs_with_known_adverse_effects on the grounds that at least they do something:

    * Similar to SSRIs: Hypericum perforatum aka St. John’s wort. Among other things it contains hyperforin, which is a reuptake inhibitor for lots of things including serotonin. Has decent-sounding evidence and is prescribed for depression in Germany. Interferes with the effects of lots of other drugs, so look up interactions before using.

    * Similar to stimulants (plus bonus decongestant!): Ephedra sinica and some others in the genus. Contains ephedrine and pseudoephedrine. Supplements containing ephedrine are banned in the US for safety reasons, but the plant is legal. The safety concerns sound legitimate and include seizures and sudden cardiac death.

    * Similar to anxiety medications: Valeriana officinalis aka valerian. Supposedly does something with GABA.

    * Similar to antipsychotics: Rauvolfia serpentina aka Indian snakeroot. Contains reserpine along with many other possibly psychoactive compounds. Unsurprisingly the side effects suck.

  33. enye-word says:

    As part of their continuing effort to pretend they are anything other than soulless profit-maximizing bloodsuckers who will be first against the wall when the revolution comes, some pharma companies offer their drugs for cheap if you can prove you need them and can’t afford the regular price.

    This was a good joke, but probably not the most accurate way to characterize price discrimination.

  34. alwhite says:

    I tried BetterHelp for a few weeks, maybe 4. Can’t say that it really helped any, but 4 isn’t enough time to get into real work. I kind of blame the therapist. The therapist didn’t appear to be putting in the effort to make a good online connection. There were many typos, bad formatting (wall of text), and the therapist put all the blame on the equipment and made no effort to improve. When a convenient excuse came up to bail, I took it.

    The website functioned ok. I could make the formatting choices I wanted to have clear communication. There was an option for video but I didn’t take it.

    The time delay of written communication seems to need a different skill that someone needs to pay attention to make therapy work well. I don’t think the therapist I got knew about this skill and wasn’t optimizing for it. This makes me think that many other therapists might also be missing this skill. As a person who does a lot of communicating over text, I think I know how to do this and that makes me believe it can be done. As with all therapy, it’s not going to work if the person doesn’t want to engage. Online/text has the added hurdle of the time delay which probably makes it less useful than face to face therapy, but I would still say it can work.

    For full disclosure, I am working on a master’s in counseling and see clients myself, so I have some knowledge on how therapy should happen.

  35. Thomas Bridgeland says:

    Re AA. Has anyone researched whether different AA groups have different results? Since they are run by their members, I would expect the groups to vary quite a lot in effectiveness.

  36. wjbrown says:

    Pastoral counseling can be a cheap route. The most famous model I’m aware of is Howard Stone’s Brief Pastoral Counseling. It’s not really designed to rework your life so much as just get you over whatever current issue is getting in your way. In my experience, it also seems to be a decent fit even for more secular people when death or a serious disease is involved.

  37. andreamedaris says:

    This is a network of sliding-scale therapists ($30-50/session, with a $50 lifetime membership fee): https://openpathcollective.org

  38. erindanika says:

    I work for Wirecutter and we just published some coverage of Mental health start ups. We have a review of several of the available services here: https://thewirecutter.com/reviews/online-therapy-services/ and blog posts on what it’s like to use online therapy and text therapy here:https://thewirecutter.com/blog/online-therapy-experience/ and here: https://thewirecutter.com/blog/text-therapy/ It’s not my responsibility to promote our work. I just saw this roundup (which is wonderful) in the morning news newsletter and thought our work (which I think our writer did a really really great job on) might be helpful to anyone wanting a little more info to help decide whether online therapy is an option for them.

  39. sparktherevolt says:

    I have used Betterhelp and I do find it lacking as well. There is some direction but I haven’t found it to be worth money yet. Feel free to contact me if you’d like to ask me more specifics.

  40. holmgrej says:

    This is a great post.

    Shameless plug here: If you’re in NYC, I’m a psychiatrist and I have made it a central part of my practice to be affordable and transparent. I charge $250 for the first 3 months of treatment, and $100/quarter thereafter. It’s not as affordable as most insurance plans (though occasionally it is more affordable), but it’s *much* more affordable than most psychiatrists. More details are at my website, and you can make an appointment there as well.

    http://josephholmgrenmd.com/

  41. jimmyred says:

    Thank you for this.