THE JOYFUL REDUCTION OF UNCERTAINTY

Should Psychiatry Test For Lead More?

Dr. Matthew Dumont treated a 44 year old woman with depression, body dysmorphia, and psychosis. She failed to respond to most of the ordinary treatments, failed to respond to electroconvulsive therapy, and seemed generally untreatable until she mentioned offhandedly that she spent evenings cleaning up after her husband’s half-baked attempts to scrape lead paint off the walls. Blood tests revealed elevated lead levels, the doctor convinced her to be more careful about lead exposure, and even though that didn’t make the depression any better, at least it was a moral victory.

The story continues: Dr. Dumont investigated lead more generally, found that a lot of his most severely affected patients had high lead levels, discovered that his town had a giant, poorly-maintained lead bridge that was making everyone sick, and – well, the rest stops being story about psychiatry and turns into a (barely believable, outrageous) story about politics. Read the whole thing on Siderea’s blog.

Siderea continues by asking: why don’t psychiatrists regularly test for lead?

Now, in my case, I’m a talk therapist, and worrying about patients maybe being poisoned is not even supposed to be on my radar. I’m supposed to trust the MDs to handle it.

Dumont, however, is just such an MD. And that this was a clinical possibility was almost entirely ignored by his training.

Dumont’s point here is that while “medical science” knows about the psychiatric effects of lead poisoning and carbon disulfide poisoning and other poisons that have psychiatric effects – as evidenced by his quoting from the scientific literature – psychiatry as practiced in the hospitals and clinics behaves as if it knows no such thing. Dumont is arguing that, in fact, he knew no such thing, because his professional training as a psychiatrist did not include it as a fact, or even as a possibility of a fact.

Dumont’s point is that psychiatry, as a practical, clinical branch of medicine, has acted, collectively, as if poisoning is just not a medical problem that comes up in psychiatry. Psychiatry generally did not consider poisoning, whether by lead or any other noxious substance, as a clinical explanation for psychiatric conditions. By which I mean, that when a patient presented with the sorts of symptoms he described, the question was simply never asked, is the patient being poisoned?

Dumont wants you to be shocked and horrified by what was done to those people, yes. He also wants you to be shocked and horrified by this: psychiatry as a profession – in the 1970s, when (I believe) the incidents he relates where happening, in the 1990s, when he wrote it in his book, or in 2000 when a journal on public health decided to publish it – psychiatry as a profession did not ask the question is the patient being poisoned?

And it didn’t ask the question, because clinical psychiatry had other explanations it liked better, to which it had a priori philosophical commitments.

And that, when you think through what it means for psychiatry, is absolutely chilling.

And:

I can tell you that, standing here in 2018:

• No mental health clinic I’ve worked at ever had the facilities for even performing blood draws, nor doing urine testing for anything other than commonly abused intoxicants (alcohol, opioids, amphetamines, etc), and then only the clinics that specialized in substance abuse treatment. The clinic I work for now can’t even do urine screens. Psychiatrists’ offices, here abouts at least, are not places blood tests are or can be performed, unless they are attached to a general medical practice. Such tests have to be referred out, usually to the patient’s PCP’s office.

• No psychiatrist has ever asked me to arrange blood draw test from the PCP for anything other than white blood cell count, thyroid panel, or Lithium blood level.

• Though I’ve seen documentation in patient charts of psychiatrists ordering two of those three tests from PCPs themselves, I’ve never seen documentation of ordering any other tests. I have literally never seen a psychiatrist order a test for any sort of poison.

• I have never seen any sort of toxicology report for poisons in any of the blood test results I have found in my patients’ discharge paperwork from psychiatric hospitalization.

• I have never, in all my case discussions with psychiatrists in-patient and out, or with hospital staff at psychiatric hospitals and hospital departments, ever heard anyone suggest anything about poisoning be a possibility in our mutual cases. Nobody has ever said anything like, “We don’t want to prescribe anything until the tox report comes back, in case it’s an environmental toxin” or “R/o env tox” or even “We don’t think there’s much chance of an environmental toxin, so we’re not bothering to test for it. It has literally never been mentioned.

• Not even when, due to the suddenness of the onset of psychotic symptoms, psychiatrists were discussing with me the possibility that a patient was intoxicated on some street drug that somehow just wasn’t showing up in his/her urine screens and blood draws.

Maybe it’s not fair for me to generalize from the psychiatrists I’ve worked with. Maybe it’s just that the psychiatrists I’ve worked with – including at MGH and McLean – aren’t representative, being somehow really bad doctors, or poorly educated, and that, contrariwise, normal psychiatrists, basically adequately well-trained psychiatrists, generally do stop to consider poisoning as a cause for severe presenting symptoms, especially when they’ve proved refractory.

I’m not getting that impression though.

I’m not getting that impression from the many interactions I’ve had with psychiatrists and other psychiatric professionals over the last decade, and neither have I been subject to exhortations of what I, as a clinical mental health counselor, should be alert to as evidence of possible poisoning in my patients.

When I was in grad school, it was briefly mentioned that most disorders in the DSM (this was version IV-tr) had a “caused by a General Medical Condition” variety, and then it was never spoken of again.

So as far as I can tell, nothing has changed.

This is not merely an incidental failure of instruction on the part of Dumont’s med school professors, nor of mine in grad school. This is, at the most charitable, a massive blindspot, of precisely the sort that “scientific” field of endeavor should never have, and it seems to afflict the entire profession.

There’s a lot more, and you should read the whole post. Siderea is a great writer and a careful thinker, so when she criticizes my practice I take note. And since I don’t think I’ve ever tested anyone for lead, this is definitely criticizing my practice. What’s my justification?

Take a look at some papers like The Emerging Role For Zinc In Depression And Psychosis and Effect Of Zinc Supplementation In Patients With Major Depression: A Randomized Controlled Trial. Done? Looks like there’s some pretty good evidence that zinc deficiency is involved in depression somehow, right? Do you think zinc is more or less important than lead? By how much?

Or what about toxoplasma? Seems to be twice as common in depressed people as in controls, and increases suicide risk 50%. Pretty suspicious; should we test all depressed people for toxoplasma? If so, is this more or less important than testing all depressed people for lead? By how much?

And when you’ve answered that, what about copper? Omega-3/omega-6 ratio? Vitamin D levels? Cortisol? Magnesium balance? The methylation cycle? Mitochondrial function? Inflammation? Covert viral infections? Covert autoimmune disorders? Paraneoplastic syndromes? Allergies? Light exposure? Circadian rhythm? Selenium? Lithium levels in your local water supply? Insulin resistance? Gut microbiome? PANDAS? FODMAPs? Structural brain abnormalities? And that’s not even getting into the psychosocial stuff!

Every one of these has some evidence of being involved in depression. Some have excellent evidence of being robustly involved. Imagine how dumb you would feel if it turned out only 0.01% of cases of depression were lead related, and you spent so much time testing your patient for lead that you never got around to asking about color temperature of their home lighting, or whether they clean their cats’ litterbox, or how many dental fillings they have.

(Dental fillings? Really? No, not really.)

Why not test all the things? Number one, cost. Number two, sticking your patient with more needles than a Trump voodoo doll owned by the DNC. But number three, everybody is weird in a bunch of ways. Have you ever gone to your doctor for labwork, and gotten a piece of paper back with a lot of words like BASOPHILS and BUN-CREATININE RATIO, and probably three or four of them were highlighted in red to indicate they were abnormal, and your doctor looked at it and shrugged and said not to worry about it? That’s because everybody is weird in a bunch of ways. Your 30-item depression risk factor panel is going to come back saying you don’t have enough selenium and your gut microbiome is off, and your doctor is going to make you spend a month eating nothing but kefir and brazil nuts, and then a month later you’ll leave your abusive partner and your depression will mysteriously disappear.

Consider prostate cancer screening. This is like the best-case scenario for universal testing. Prostate cancer is pretty common – about 10% of men are diagnosed with it sometime during their lives. We know who’s most at risk – older men. It’s potentially pretty bad – nobody wants cancer. The test is easy – the same simple blood draw that tells you if your cholesterol is too high. And yet governing bodies keep recommending that doctors stop screening for prostate cancer (recent guidelines are nevertheless complicated: ask your doctor if PSA screening is right for you). The bodies cite possibility of “overdiagnosis and overtreatment”, potential false security by missing some cancers, and studies which show no decrease in mortality. Breast cancer screening organizations keep pushing back the age at which they recommend women start getting mammograms, because the costs outweigh the benefits before then.

Doctors never just say “I hear this condition is bad in my field, let’s worry about it with everyone who comes through the door”. They want really good evidence that it’s common enough (and that testing works well enough) that the benefits are worth the risk. Right now for lead, we have no such evidence.

The only study I have ever seen even begin to make the slightest attempt to quantify the role of lead in depression is Bouchard et al. It claims that people in the highest quintile (top 20 percentiles) of lead exposure have twice the depression risk as people in the lowest quintile. Big if true. But I’m skeptical, for several reasons:

1. Lead exposure is heavily linked to poverty – poor people tend to live in the decaying houses and polluted neighborhoods where lead is most common. Poor people are also more likely to get depressed. The study attempted to control for poverty, but this never works. So it’s not clear how much of the lead effect they picked up was really a poverty effect.

2. This is an implausibly large effect size. The amount of environmental lead has plummeted over the past thirty years after the removal of leaded gasoline. Since then, the percent of people with elevated lead levels has decreased by a factor of twenty. Some quick calculations suggest that if this study were right, depression rates should have gone down 66% in the past few years. They haven’t. Compare this to violent crime, which we have better evidence is lead-related and which did decrease by a factor of 2 or 3 over the past few years.

3. I don’t entirely understand what they’re doing with statistics here. In Table 2, every lead quintile has about the same depression rate. It’s only after they apply their model that they find higher-lead people have higher depression. This is sort of a red flag for the kind of thing that might not replicate later on. Nobody else has ever tried to repeat this study and as far as I know it remains the only investigation into the epidemiology of lead and depression.

Aside from this study, we have nothing to guide us. Does lead contribute to 5% of cases of depression? 0.5%? 0.0005%? I’m not sure anyone knows.

If it’s 0.0005%, then we’re talking about people who work in lead mines, or Dumont’s patient who scrapes lead paint off the wall every day. I agree if your patient works in a lead mine and has any problems at all, you should test them for lead poisoning. This is why your doctor asks you what line of work you’re in when you go in for an evaluation. She’s not trying to make small talk – she’s waiting for the one guy who says “I French kiss cockatiels for a living” so she can diagnose him with psittacosis.

I am definitely not going to make every patient take a blood test just so I can catch 0.0005% of people. But should I be more careful in the history here? Specifically ask patients “Do you have any hobbies that put you in contact with lead?”. I’m not sure – right now I have no intuition for whether that’s more or less important than “Do you do anything that might cause zinc deficiency?” or “Do you clean out cat litterboxes?” Usually what I do is I ask broad open-ended questions to start with, and then as the depression proves itself weirder and more treatment-resistant, we gradually go one-by-one down the list of super-rare causes that never happen in real life so I can be sure I’m not missing anything.

What if lead causes more like 5% of depressions? In this case, we’re talking about people with no specific exposure factors. Maybe they just live in an old house, or a bad neighborhood, or got a bad draw in the genetic lottery for whatever systems affect heavy metal removal. So suppose I grudgingly give every patient who comes through the door a blood lead level test. Lots of them come back with lead levels in the top quintile – just like 20% of the general population would. Now what? I say “Your lead level is within the normal range, I have no proof that it’s contributing to your depression at all, but just to be safe you should move to a classier neighborhood”? “Oh, you mean that will cure my depression?” “No, Dr. Dumont didn’t even cure his patient’s depression when he made her stop scraping lead paint off the walls, I’m just saying it probably couldn’t hurt”. I consider it a good day when I can get my patients to take their Lexapro without missing any doses. My ability to get them to move to a nicer neighborhood – most people aren’t living in bad neighborhoods just because they never thought of moving to a better one – is pretty low, especially when I can’t even honestly say I expect it to help that much.

What about chelation therapy, a series of techniques that suck lead out of the body? From Wikipedia: “Chelation therapy must be administered with care as it has a number of possible side effects, including death…various health organizations have confirmed that medical evidence does not support the effectiveness of chelation therapy for any purpose other than the treatment of heavy metal poisoning.” If you chelate everyone who comes through the door with high-average lead levels, there’s no guarantee you will cure any depressions, but you will definitely kill some people.

There’s an old medical maxim: never do any test if you have no plan for acting on the results. What’s my plan for acting on the results of a upper-end-of-normal lead level? I really don’t have one. If it’s an extreme level, the 0.0005% works-in-a-lead-mine type, then I can at least demand the patient find a different line of work. But if I’m just going to be diagnosing 20%+ of the patients who come in the door with upper-end-of-normal lead? Forget it.

I understand Siderea probably isn’t recommending universal blood lead screening. But then I’m having trouble figuring out what she is recommending doctors do differently. Ask everyone some history questions to see if they work in lead mines? We try to do that kind of thing already. Have lead poisoning on the top of our minds and ask a lot of really intense history questions to ferret out any possible exposure? Not clearly privileged above doing that for the thirty other rare causes of depression. Just make sure to talk about lead as a cause of depression in medical school? They already do, it’s right between “Prader-Willi Syndrome as cause of obesity” and “Q fever as cause of pneumonia” in the lecture series entitled Extremely Rare Causes Of Common Symptoms Which Ideally You Can Keep In Mind And Have Dr. House Levels Of Diagnostic Genius, But Let’s Be Honest Here, Realistically Over Half Of You Will Prescribe Antibiotics For Viral Infections.

I’m not saying nobody should worry about lead poisoning and depression. I’m just saying those people shouldn’t be front-line clinicians. Some epidemiologist should absolutely be trying to replicate Bouchard et al’s work on the magnitude of the lead-depression correlation. Some guideline-making body should be coming up with a guideline for when doctors should take lead levels, and what results should prompt what kind of action, even if the guideline is just “never worry about this unless somebody works at a lead mine” (which is plausibly the right answer given the current paucity of data, but I’d feel more comfortable if a guideline-making body said so officially). And public health officials should worry a lot about how to decrease lead on a society-wide level (which they’re already doing, albeit for different reasons), since that’s much higher-yield than some random doctor telling a poor person to move to a different house.

But I am not sure the average clinician needs to think about this too much.

(Maybe Siderea already agrees with me here; I can’t tell.)

There are thirty-plus plausible causes of depression that nobody knows enough about to be sure they’re real, estimate their magnitude, or begin to treat. If you look at any one of them too closely, you will come to the conclusion that every psychiatrist in the country is a quack who’s ignoring the evidence right in front of their eyes and willfully blind to the role of [lead/zinc/toxoplasmosis/inflammation/gut microbiome/etc] in order to keep getting the sweet pharma company cash for prescribing Lexapro. It’s not that we don’t know about these things. It’s that we don’t have an action plan. We don’t have a good feel for when to do the tests, what numbers on the tests mean we should do something, what that thing should be, and whether it should work. So we punt the question to the researchers, who already have a backlog of ten million other things they need to be working on.

This isn’t a great state of affairs. But I only know three ways doctors can deal with it, and none of them are very good.

The first is the one I learned at age 3 from my father teaching me to read out of evidence-based-medicine textbooks. You insist that nothing can be admitted into the medical canon unless it has some guideline-making-body’s stamp of approval, which the guideline-making-body will not give until a bunch of randomized controlled trials have validated every step of the model and shown that the proposed solutions definitely work on a large scale with every demographic of patient. Until then we will keep doing the things that have met that bar – which is basically giving people Lexapro and telling them to diet and exercise. This path assures you a long and prosperous career as a respected member of the medical establishment.

The second is to become Dr. Oz. You fall in love with anything that has an even slightly plausible mechanism and at least one n = 15 study saying it works. I’m not talking about literal homeopathy here. I’m talking about things where if you ask a biologist whether it works, they just sort of shrug and say “well, it should“, and there’s a bunch of respectable research into it. But this is a really low bar, and if it’s the only one you hold yourself to, then you’re going to be the guy telling your patients they need heavy metal tests and vitamin levels and SPECT brain scans and screens for twenty latent infections just because they came in saying they’re tired all the time. This path assures you a lucrative daytime TV show and a side gig selling supplements with your picture on them.

The third is to be a generally respectable doctor with one Big Idea. Like “why aren’t we testing everybody for lead?” or “why don’t we care more about the gut microbiome?”. These people are often really good at what they do, really passionate, and mostly within the mainstream. Sometimes they are impressive researcher-crusader-prophets, they get their Big Idea universally adopted, and then they become the next generation of medical orthodoxy. Other times they’re just annoying clinicians who love saying “I see you aren’t even testing for cortisol levels, clearly you have no interest in going beyond Textbook 101 Level” but can’t really explain why this is better than the twenty-nine other things you might consider doing. This path assures you a long bibliography of successful articles in The Journal Of Medical Hypotheses.

I love everybody in Group 3, they’re all great people. But the thing is, if I were to believe everybody in Group 3, then I would end up as Group 2 – and I don’t have enough time to star on a TV show, so screw that. I think that makes me Group 1 by default, which is good, because otherwise my family would disown me.

“Shouldn’t we be able to use rationality techniques to figure out which of the Group 3 people are right, and move faster than guideline-making bodies“? Well, that’s the dream. But take that route, and you notice you’re wading through ankle-deep skulls. I occasionally flirt with trying this – like every doctor, my practice has a few idiosyncrasies and places where it deviates from the exact textbook solutions. But I would be nervous putting too much trust in my own gut.

This is all context for how to think about questions like “should we test everybody for lead?” or “should we think more about lead?” or “is the psychiatric establishment incompetent for not testing lead more?” The prior on the psychiatric establishment being incompetent is never that low. But the prior on any given alternative being especially fruitful isn’t great either.

[EDIT: The only general medical conditions I consistently find worth worrying about in depression (absent some specific reason to worry about another) are hypothyroidism and sleep apnea. I test a lot of people for anemia and various vitamin deficiencies, because the guidelines say so, but I’ve never found them too helpful. Curious if anyone else in the field has different experiences. I recently had one patient obtain a miraculous and lasting cure of his chronic fatigue using nasal steroids (ie it was apparently caused by nasal inflammation from allergies) but nobody ever talks about that and I’m not sure if it was just a fluke.]

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116 Responses to Should Psychiatry Test For Lead More?

  1. userfriendlyyy says:

    “The thousands of U.S. locales where lead poisoning is worse than in Flint”
    https://www.reuters.com/investigates/special-report/usa-lead-testing/

    “Hundreds more lead hotspots are identified as Trump prepares to gut programs”
    https://www.reuters.com/investigates/special-report/usa-lead-states/

    Not to say you should be testing everyone, but a location based rule might be useful.

    • jessriedel says:

      Broad regions with slightly-higher-than-average lead levels (e.g., lead leaching into the water) may not actually have a higher number of people with very high levels (e.g., weirdos eating paint chips) who, presumably, are the people psychiatrists need to be on the lookout for. (This is true even if, statistically, the slightly high levels for lots of peoples does more harm.)

      • SaiNushi says:

        But if it’s in the water, it’s going to get in the people, even if they don’t eat paint chips. Even if you buy bottled water for consumption and don’t drink from the lead-laced taps, you’re still bathing in it, brushing your teeth with it, and washing your dishes with it.

        Also, I lived in an apartment with lead paint for awhile. When we moved in, my partner and I joked about “so we just don’t eat the paint, no biggie”. Boy were we wrong. Within two months, he had broken furniture due to temper outbursts. Turns out, the paint sheds as powder even if it’s not chipping, and that gets in the food no matter how careful you are.

        • Nancy Lebovitz says:

          I was wondering whether people with impulsiveness problems should be tested for lead.

        • baconbits9 says:

          Also, I lived in an apartment with lead paint for awhile. When we moved in, my partner and I joked about “so we just don’t eat the paint, no biggie”. Boy were we wrong. Within two months, he had broken furniture due to temper outbursts. Turns out, the paint sheds as powder even if it’s not chipping, and that gets in the food no matter how careful you are.

          What is infuriating about trying to understand causes is that it might not have been the lead in the apartment that did it (though probably), there are many different ways t be exposed and some unfortunate section of the population is going to end up with poisoning and moving out and then not getting better because (part of) their contamination was coming from somewhere else.

    • Edward Scizorhands says:

      Last I heard on NPR, Flint is under the legal limits for lead, so “lots of places worse than Flint” doesn’t mean much.

      *EDIT* looking for a source, I’m initially finding things saying I’m wrong.

      *EDIT* The EPA limit is 15 ppb and Flint is less than 5 ppb. This WaPo article (from 2016) talks about “no safe level” but that means 100% of locales are at risk. I think this article is playing tricks but it’s still a good overview of the issue. https://www.washingtonpost.com/news/wonk/wp/2016/01/15/this-is-how-toxic-flints-water-really-is/?noredirect=on&utm_term=.b979fcea371f

      *EDIT* I believe this is the NPR story I heard, since it was timed at the end of the bottled water giveaway. It says that the water is safe but the citizens won’t believe it. https://www.npr.org/2018/04/10/601268214/in-flint-residents-scramble-to-get-the-last-cases-of-state-provided-bottled-wate

      • userfriendlyyy says:

        Thousands worse than Flint 12/19/16

      • Yosarian2 says:

        One problem with lead in water from lead pipes is that it’s not necessarally consistent, especially when they’re doing construction to replace the lead pipes (which they slowly are in Flint) which occasionally cases disruptions and breaks up the film on the lead pipes that are still there. It’s fairly common to see a case where the water is within legal limits on the day they test it, but is higher at other times.

        There was recently an example like that in a school in Philadelphia; they have been trying to test all the water sources that children drink from for lead lately, and one old water fountain in the school tested within safe levels when they tested it, but on the day after Christmas break (when the water had been sitting in the pipes for a few weeks) it was much higher, at a very dangerous level.

  2. Evan Þ says:

    Thank you very much for this post, Scott. I was shocked and horrified when I read Siderea’s original blog, and you’ve explained how no, the medical establishment is not being willfully blind.

    (Well, at least probably not this time.)

  3. Klaymen says:

    “If you chelate everyone who comes through the door with high-average lead levels, there’s no guarantee you will cure any depressions, but you will definitely some people.”

    You accidentally left out the word “kill” between “definitely” and “some”. I don’t normally care about typos but this one steps on your snarky quip!

    • tcheasdfjkl says:

      is “you will definitely some people” like “you accidentally a word”

    • Randy M says:

      Similarly

      The first is the one I learned at age 3 from my father teaching me to read out of evidence-based-medicine textbooks. You insist that nothing can be admitted into the medical canon [unless] it has some guideline-making-body’s stamp of approval

    • Carey Underwood says:

      Mustn’t discount the possibility that he’s testing variations on the the usual theme.

  4. Majuscule says:

    I second you on hypothyroidism. I never had any overt thyroid symptoms, and it was only because a sharp-eyed nurse practitioner noticed a high number in routine bloodwork, suggested I get a follow-up thyroid panel, and then *explained that I’d need to get tested repeatedly* that I got diagnosed and treated. But I used to get occasional bouts of depression and weeks-long episodes I can only describe as a low-grade, persistent sense of dread. Again, nothing serious enough that I sought medical or psychiatric help, but sufficiently unpleasant. Once I started regulating my thyroid, though, both of those things mostly stopped.

    Since then, I’ve met a lot of people who seem to have thyroid symptoms, sometimes serious ones, but who had their thyroid levels tested once, got a normal result, and never pursued it. But I had several thyroid panels before the pattern emerged. So someone not only needs to suggest a test, but explain how thyroids work and why repeated testing is probably necessary. That’s a tough sell for both doctors and patients, but given how many people only figure out they have a problem when their thyroid starts trashing their entire body, maybe it’s worth it?

  5. AndyMcKenzie says:

    My guess is that the nasal steroids improved his sleep. This is an extremely common phenomenon and nasal corticosteroids should be used more widely IMO. They have recently become pretty cheap too.

    https://www.ncbi.nlm.nih.gov/pubmed/16337455

  6. Aevylmar says:

    Wow. I have family risk for both hypothyroidism *and* sleep apnea.

    I probably ought to get formally tested on those and see if my depression improves.

  7. bean says:

    She’s not trying to make small talk – she’s waiting for the one guy who says “I French kiss cockatiels for a living” so she can diagnose him with psittacosis.

    The Bay Area must be weirder than I thought if you can make a living doing that.

  8. coraharmonica says:

    The craziest part of Sideria’s excerpts for me isn’t the lead poisoning, but the modern psychiatric paradigm wherein discussions of causes of mental illness outside universal causes (e.g. neurotransmitters and vitamins) are rare. We can classify causes in scientific terms with studies, but psychiatrists will miss the local cases without a level of intimacy with their patients. The psychiatrist could have easily known about the patient’s routine lead exposure through a simple walk through the patient’s house, or a simple physical exam, but when the system is anonymized as with psychiatry, it’s easy to assume your patient is “normal” outside of whatever they tell you.

    For me the interesting question is: What besides lead poisoning is our paradigm ignoring? How many cases of pseudo-depression caused by [lead poisoning, grief, etc.] are mistaken for real depression caused by [neurotransmitters, abuse, etc.]? Is it wrong to give someone SSRIs if their depression is caused by lead poisoning? Which of these causes do we take seriously and why?

    • Douglas Knight says:

      Is it wrong to give someone SSRIs if their depression is caused by lead poisoning?

      Morally wrong? Of course not. But do they work better or worse in the case of lead? Answering that question is the only useful thing that one could do to address the post. Until then, one should not test for lead.

      • coraharmonica says:

        Even if SSRIs work with lead in the system, doesn’t there linger a moral question of whether you should give her SSRIs when she wouldn’t need them without lead poisoning in the first place? If her depression isn’t (directly) causally related to neurotransmitters, why give her antidepressants? SSRIs might treat the symptoms but not the cause, and then you have someone who never needed SSRIs on antidepressants until [indefinitely], and with lead poisoning, whereas you could have had an outpatient with neither lead poisoning nor SSRIs.

        I think the broader question behind my post is: how do we diagnose and treat a condition like depression with multiple (often labyrinthine) causes? If treatment and recovery depend on etiology then the cure needs to be crafted to fit the cause, but depression has so many causal factors that it can be difficult for an anonymous clinician to parse which ones are relevant to a certain patient, even though this might be obvious if they were e.g. the patient’s friend. Is someone clinically depressed if they exhibit depressive symptoms due to non-psychological causes that could be solved, just not (likely) by their psychiatrist? I’m just wondering how many other cases there are like this, where someone with a non-psychological problem exhibits psychological symptoms and it’s presumed their problem is psychological.

        • Douglas Knight says:

          Sure, if you know of acute lead poisoning, you should address it. But you should also stick to the drugs until you do fix it. And if you know of mild lead poisoning, there’s probably nothing you can do and you should stick with drugs. It’s not worth testing for the lead to discover such an exotic possibility. Maybe it’s worth walking through the patient’s house because that could catch lots of exotic possibilities.

        • Doctor Mist says:

          coraharmonica-

          SSRIs might treat the symptoms but not the cause

          Wait, isn’t that what SSRIs always do?

          I’m not trying to be dismissive here: SSRIs were very helpful to me when I was depressed, but my perception was that they took enough edge off my condition for the talk therapy to be effective.

          But I don’t know of anybody who thinks that they cure depression, the way antibiotics cure an infection — if SSRIs are your only treatment, and a year or two later you successfully wean yourself from them and are no longer depressed, then probably you would have gotten better over a similar time frame except you’d have been more miserable in the meantime.

          Scott will probably tell us whether I am oversimplifying.

          • coraharmonica says:

            I’m not sure whether SSRIs always treat the symptoms–what if successfully treating the symptoms is contingent on treating the cause first? There are two possibilities: 1) SSRIs categorically decrease some unhappiness factor (thus working for anyone who’s depressed), or 2) they work for people who are depressed for one reason but not another (thus they would work for someone with a genetic chemical imbalance but not someone with lead poisoning). As far as SSRIs go, there might be a difference between depression-as-caused-by-lead-poisoning vs. depression-as-caused-by-[other], one which SSRIs can’t help and another they can.

            This is speculation, but my personal intuition is that SSRIs probably don’t work for depression regardless of causes (this would explain the trial-and-error in many treatments). Depression caused by e.g. low sunlight might not remit with antidepressants in the same way as depression caused by genetic factors. Depression caused by trauma might even be more responsive to CBT or therapy than chemical treatments. Extra-genetic factors like sunlight, trauma, lead poisoning, etc. with solutions beyond SSRIs seem to impose a limit on how thoroughly they can treat depression.

          • Doctor Mist says:

            Sure: I didn’t intend “always” to mean “unfailingly”, but rather “fundamentally” — that they never address the “root cause” of a depression, but rather (merely?) alleviate its symptoms so that the healing process is more tolerable and so that the symptoms don’t open you up to additional problems.

            Again, I hold this opinion mainly through introspection. I seem to recall that Scott has written about something — ketamine? — that seems to have the property that taking it once actually eliminates depression, forever or at least for way longer than you’re likely to have the substance in your body. But I’m talking about SSRIs.

    • Cheese says:

      I’m not sure if there’s necessarily a great issue with ‘what is our paradigm ignoring’ in terms of the actual treatment of depression. Depression is not really discussed in medical circles in terms of, say, a wholly neurological cause like neurotransmitters – the psychiatric establishment is very much aware that there are predispositions both genetic and environmental, potential triggers and that there are temporary mimics i.e. grief (which can become depression of course). It’s just that knowing all that isn’t currently that useful. With respect to grief, and Scott will have way more knowledge than I do, there are specific extra characteristics that are required to make a diagnosis of depression which are usually not seen in grief to the extent that they fulfil that requirement.

      I mean, we don’t really know how depression works. We pretty much know it isn’t neurotransmitters on their own or as the primary (or even probably a secondary cause), it just so happens that the drugs which we know work affect neurotransmitters and then an unknown number of steps down from that they also have a myriad of other effects (on inflammation, synaptic and dendritic architecture, receptor splicing/editing/regulation, probably a bunch of others we don’t know about) which kind of solve the problem.

      Of course, the fact that response rate is pretty low (e.g. response rate ~47% to a first line SSRI from one major study) and that people generally have to try a few different drugs suggests that yeah maybe there’s a qualitative difference between depressions. But that’s fine, we know that – DSM criteria are kind of more designed to catch a clinical syndrome with common features rather than a specific aetiology (and this is a pretty key point). Because we just don’t know the latter, excepting the known organic causes that you have to exclude anyway – thyroid, adrenal, pituitary, MS, etc etc etc (well I mean we don’t know the how, we just know the ’cause’). And I would say that I think that for these known organic causes, they’re pretty well established in medicine as ‘things you should think about or actively exclude (clinically or with investigations) before referring to psych’.

      What you seem to be alluding to here is the stuff Scott is talking about where some study has picked up some association but it hasn’t been properly investigated or verified. Which is kind of his point I think – there’s not much use thinking about it beyond the really extreme cases because we just don’t know the what how when where why who of its relationship to depression. I guess what i’m saying is that we can’t really make a judgement about what we’re ignoring because we don’t know what we’re actually doing really. We just have a definition of a clinical syndrome which seems to catch people with ‘depression’ pretty well, and some drugs which seem to work pretty well (in terms of NNT they’re actually not that bad tbh compared to a lot of other commonly used medication) if you’re willing to be patient and play around a bit. It’d be great if we knew more, which is kind of what Scott alludes to, but at this point the answer is kind of ‘well yeah that’d be great but given our current level of knowledge about the brain and depression’-*shrug*.

      I guess i’ve struggled to actually address your main point, but I would say that I don’t necessarily think that medicine is really that ignorant of other potential causes of psychiatric problems than straight neurological dysfunction. It’s just that, outside of common organic causes or your dad just died in a car accident, we really don’t know how all this other stuff fits in or how to fix it.

      • coraharmonica says:

        With regards to the variety of causes the psychiatric community already knows, I suppose knowing the causes doesn’t help when it comes to individual patients, since each new patient starts from square one (i.e., the psychiatrist has no priors beyond those that would apply to a stranger). You can do all the science and know all the factors, but that can only take you so far on its own without sufficient background.

        My qualm isn’t with outright ignorance so much as lack of communication: even if psychiatrists are aware of factors that contribute to depression, or even if they have perfect knowledge of its full etiology, it seems there would still be cases like Dr Dumont’s, where simple lack of knowledge of what the patient is going through prevents the doctor from a successful diagnosis. I worry how many patients go home not knowing what’s wrong with them when their doctor could recognize the problem in an instant if only they knew what the patient knew about themselves. I think we might undervalue this kind of doctor-patient intimacy as a means of improving treatments (or overlook when a lack of doctor-patient intimacy hinders treatment)–as if you only need a doctor who knows all the science, when really you need a doctor who knows all that and knows the relevant things about you, too.

        Scott pointed out the need for intuition in selecting treatment options and which science to follow. I think, though, that you also need a kind of social intuition, one which tells you which questions to ask your patients, which to linger on, etc. Without scraping the relevant data from your patients, knowing the full causal spectrum won’t do much good. It seems a psychiatrist would fall flat without knowing the right details, even with perfect knowledge of depression (though you may want to debate me on that), which suggests to me that we would benefit from clinicians knowing their patients to a similar extent that they know the current science.

  9. Fakjbf says:

    This reminds my of the episode of Scrubs “My Lunch”, in which a patient dies of what they think is a drug overdose and her organs are given to people currently in critical need of a transplant. An autopsy later shows that it wasn’t a drug overdose but actually rabies, and all three transplant patients die. When one of the doctors blames himself for the mistake, another doctor points out that there are only a half dozen reported cases of rabies per year in the US and it would have been irresponsible to deny the transplant patients treatment in order to wait for lab results that they would have had no reason to expect to come back positive.

  10. Douglas Knight says:

    But then I’m having trouble figuring out what she is recommending doctors do differently.

    She is recommending that doctors become environmental activists.

    Siderea is a great writer and a careful thinker

    • honoredb says:

      It seems reasonable to say that doctors should be able to pivot, in extremity, to being public health doctors. If a bunch of your patients have been poisoned, you may be the person in the best position to realize that, and/or the highest-impact thing you could do might be to address the underlying causes, even if that’s not your speciality.

      And then sometimes being a public health doctor means environmental activism, because sometimes the poison is coming from the environment and it takes power to make that stop.

      Of course, if you accept that reasoning, that does imply that doctors should sometimes be doing tests even if the results wouldn’t be helpful for that particular patient. Forensics is a thing.

  11. Godfree Roberts says:

    We need a psychiatry blood panel for this. A real money-spinner, too,

  12. Quixote says:

    “1. Lead exposure is heavily linked to poverty – poor people tend to live in the decaying houses and polluted neighborhoods where lead is most common. Poor people are also more likely to get depressed. The study attempted to control for poverty, but this never works. So it’s not clear how much of the lead effect they picked up was really a poverty effect.”

    I’m not sure how much of the poverty they picked up was really a lead effect.

    Lead is a really really big huge deal. Lead is one of the really very few things in the world where effect sizes can’t be implausibly big.

    • pdbarnlsey says:

      I feel like your ability to claim this is itself confounded by problems with the evidence base and correlations between lead exposure and other things that lead to bad outcomes – or are you starting from a basis in purely biological rather than public health studies?

  13. Murphy says:

    I’m with scotT 100% re: multiple possible treatments though one sentence jumped out at me from the quote:

    because clinical psychiatry had other explanations it liked better, to which it had a priori philosophical commitments.

    My SO is a mental health nurse, I work in neuro genetics research.

    What this means is that mostly I spend my days learning about weird genetic disorders, many that effect the brain in weird ways and our lab meetings cover research into things like genetic variants linked to psychosis or weird neuro prototypes. She meanwhile sees a long procession of people where they’re not allowed just blame the parents… but a lot of the time it’s that people have been royally mentally fucked up by nutty parents along the lines of anorexic patients who’s parents sneak diet pills to them because they’re “getting a little tubby”.

    But this also means that most of the reasons I hear about for various problems are mechanistic, physical, genetic.

    (And I’ll admit that just getting mentally fucked by a parent or partner is probably the main factor in a large chunk of cases. )

    But it’s interesting to me that when I talk about that stuff with her or people she works with there’s a sort of dismissive view of physical issues related to the brain like if I walked into a room filled with philosophical dualists and started talking about the brain from a purely materialist point of view.

    There’s definitely a philosophical divide there where many in mental health seem to believe that experiences and emotions are almost all and that mere physical things are the tiny rounding error at the end that they only mentioned in classes to note that there was this one guy once in a land far far away who turned out to have a boring physical reason for his mental health problems.

  14. zzzzort says:

    There are thirty-plus plausible causes of depression that nobody knows enough about to be sure they’re real, estimate their magnitude, or begin to treat.

    I don’t know, thirty doesn’t seem like that many to me. If the depression is enough of a problem to go through half a dozen medications to find the right one, or to go through months or years of talk therapy, then it doesn’t seem that hard to do a couple of blood draws and test for as many as you can.

    The treatments seem easier than what you suggest. Things like zinc deficiency are of course easier to fix than lead exposure. And even for lead exposure there are steps short of moving into a different house, such as wet wiping windows and removing shoes when entering the house (from https://www.cdc.gov/nceh/lead/tips.htm). And if the result ends up being that they’re told to try a multivitamin or eating some yogurt, the downside doesn’t seem overly onerous.

    Finally, I think it’s a bit odd that more doctors don’t do this, because it seems to be clearly what patients want. No one wants a incurable genetic condition, possibly exacerbated by poor lifestyle. They (let’s be honest, we) want Dr. House to find the one weird trick to making us healthy again. I don’t know if that means that doctors are really willing to go against their patients wishes for the patients own good, or if medicine as a market does not adequately incentive consumer satisfaction.

    • baconbits9 says:

      There are many issues with a broad screen and attempting to address the “problems”, one of which is that getting someone struggling with depression to commit to a single course of treatment is difficult in itself, what happens when your screen comes back with 3 “positives” any one of which may, or may not be the cause? Are you going to prescribe anti depressants +X+Y+Z to someone struggling to get out of bed in the morning and then also put them on a course of CBT at the same time? Are you going to treat one, wait 6 – 10 weeks to see if its effective and then try another? Are you going to treat one, wait 6-10 weeks and then treat another while maintaining the first treatment or tapering it off or cutting it off cold turkey?

      • zzzzort says:

        The gold standard for environmental cause seems to be diet and exercise. Are you saying that currently physicians tell people to improve diet, but not exercise, wait 6 weeks, then add exercise, wait 6 more weeks, then CBT? That would be silly. The difference isn’t adding combinatorics of x/y/z, it’s going from ‘eat right and get some exercise’ to ‘eat right, get some exercise and take a multivitamin that has some zinc’.

        This works because most of these things are not great for you anyway. Even if your selenium deficiency isn’t causing your depression, it’s probably still better to get some selenium anyway. To the extent that some of the weird theories are hard to test for/hard to treat/don’t affect other health outcomes, that at least gives you a way to pick among the dozens of proposed crazy theories.

        • baconbits9 says:

          No, that is not what I am saying. However if you were to suggest diet and exercise changes in a patient you probably wouldn’t also put them on an antidepressant at the same time, first off because some anti depressants have side effects that would make improving diet more difficult, and secondly because you don’t know which change has caused any improvement or if the combination all together caused the improvement so you are sort of stuck with “well, this is your new life”.

        • jensfiederer says:

          And today I learned ANOTHER meaning for “CBT”.

          OK, apparently I have weird friends.

    • carvenvisage says:

      I don’t know, thirty doesn’t seem like that many to me. If the depression is enough of a problem to go through half a dozen medications to find the right one, or to go through months or years of talk therapy, then it doesn’t seem that hard to do a couple of blood draws and test for as many as you can.

      The treatments seem easier than what you suggest. Things like zinc deficiency are of course easier to fix than lead exposure. And even for lead exposure there are steps short of moving into a different house, such as wet wiping windows and removing shoes when entering the house (from https://www.cdc.gov/nceh/lead/tips.htm). And if the result ends up being that they’re told to try a multivitamin or eating some yogurt, the downside doesn’t seem overly onerous.

      Seconding that I don’t get this.

      Last time I was in hospital, I filled out a two or three page form with many questions I didn’t understand the relevance of, which I’ll admit was mildly onerous, -but no more so than driving to the hospital (or doctor) and sitting in a waiting room for god-willing-no-more-than-an-hour. Certainly I would be willing to do a lot more than this for a drastically life changing problem liable to prove treatment resistant.

  15. JulieK says:

    There’s an old medical maxim: never do any test if you have no plan for acting on the results.

    That sounds like it should be a rationality maxim as well.

    • andrewflicker says:

      It’s a maxim in my field, business analytics & testing, as well. Never measure something you won’t act upon.

    • RC-cola-and-a-moon-pie says:

      This may make sense for physicians but as a matter of general rationality wouldn’t there be lots of situations where something is important to know but you wouldn’t want to waste time figuring out a plan of action unless the test reveals the need to spend the larger investment required to do so? I suppose you could say “figure out what to do if I test positive for x” is itself a skeletal kind of plan for action of sorts, but if so then the maxim becomes trivial (reduces to more or less “don’t test for x if you don’t care about the results”).

    • ordogaud says:

      I would say good maxim in general for practical or applied fields. But in theoretical fields or if you’re just doing some exploratory testing it might not make sense and could even prejudice the results.

  16. rahien.din says:

    Siderea is a clear and compassionate thinker, but she doesn’t seem to understand medical decision-making.

    We do a test if and only if the combination of test characteristics, treatment characteristics, and pre-test probability indicates that we can reasonably obey the test’s results. If we wouldn’t treat the patient even if the test was positive, we shouldn’t test or treat. If we would treat the patient even if the test was negative, we should treat the patient without testing. If we would treat all positives and not treat all negatives, we should do the test and treat the patient if it is resulted positive. It’s that simple.

    What I want to know is why this guy gave TCA’s to an actively suicidal patient. TCA’s are ferociously lethal in overdose. CMWIW but this strikes me as malpractice.

    Do you find that the described degree of somatic delusion and treatment refractoriness is common in run-of-the-mill depression? Seems to me that should have pointed him to a broader differential diagnosis in the first place.

    • Douglas Knight says:

      I think giving tricyclics to suicidal patients was totally normal. It’s a pretty small risk. Two things have changed with the advent of SSRIs. One is that they seem totally safe, so that people look askance at the small risks of earlier drugs. The other is that the use of antidepressants has widely expanded, so that the potential benefit of treatment has decreased, while the risk of a suicide attempt probably doesn’t depend much on severity of depression. Maybe the psychiatric community should have preferred MAOIs for suicidal patients (although I don’t think this really was “actively suicidal”), but I don’t think that they had thought this through.

      • rahien.din says:

        I think giving tricyclics to suicidal patients was totally normal.

        Yeah, I have to revise. He specifies that this happened in the pre-SSRI era.

        Disagree about the riskiness thereof, though. TCA’s are highly lethal in overdose.

  17. b_jonas says:

    Can you clarify the cat litterbox thing? How is that related to depression? I don’t see a link in your writeup for that one.

    > You insist that nothing can be admitted into the medical canon it has some guideline-making-body’s stamp of approval, which the guideline-making-body will not give until a bunch of randomized controlled trials have validated every step of the model and shown that the proposed solutions definitely work on a large scale with every demographic of patient.

    I think there’s a conjunction or something missing from this sentence.

  18. Maxwell says:

    “And yet governing bodies keep recommending that doctors stop screening for prostate cancer (recent guidelines are nevertheless complicated: ask your doctor if PSA screening is right for you). The bodies cite possibility of “overdiagnosis and overtreatment”…”

    So they’re saying you should avoid testing for a deadly, curable (if caught early) disease because doctors are terrible? Seems like the advice generalizes to avoid doctors. Or else an explanation is needed for why doctors can be trusted with everything except prostate cancer.

    • Ozy Frantz says:

      No, it’s because people are terrible.

      Most people, when they get a cancer diagnosis, are going to expect Something to be Done. If the doctor says “oh, we’ll keep an eye on it and see what happens,” they’ll say “that quack is trying to kill me” and go to a different doctor. For prostate cancer, the vast majority of the time, the right course is to keep an eye on it and see what happens; treatment has side effects and most prostate cancer is slow-growing enough that you’ll die of something else.

      You should get treatment for anything where watchful waiting isn’t the right course.

      • Edward Scizorhands says:

        I think this is the #1 reason bringing European-style healthcare* would be so difficult, or implemented without the hard choices so that it would be a disaster. Americans won’t defer to government authorities.

        * I am rolling a bunch of very different systems under one label, incorrectly, which is part of the problem, but for this comment those differences don’t matter.

        • rlms says:

          I don’t want to start yet another big healthcare argument, but I don’t understand what you mean. Americans are already deferring to authorities (the one linked in the post doesn’t actually seem to be governmental but I don’t think it really matters) in that doctors are advised not to screen for prostate cancer, but having them defer in the sense of the government mandating certain policies wouldn’t be copying European-style healthcare.

          Firstly, the whole NHS idea is limited to pretty much just the UK and Canada. Most European countries have mandatory-insurance type systems that are basically Obamacare but well-functioning and with more redistribution. The government has no greater role in mandating treatment than in the US.

          But even in places with an NHS, although the government *can* force the NHS to make specific choices, that firstly doesn’t mean that they do and secondly doesn’t stop people from seeking private treatment. In the specific case of cancer screenings, the first point is more relevant: AFAIK, guidelines mean that e.g. women under a certain age will not be automatically invited for screenings, but can still have them under the NHS if they want.

          • Saint Fiasco says:

            I’m not American, but I imagine that if a patient wants to get a test for prostate cancer, their doctor might say something like “your insurance won’t cover it” and the patient will be mad at the insurance company. If they said something like “the Ministry of Health says it’s not cost-effective to do so” the patient will be mad at the government.

            But more important than the target of the rage is the intensity. Insurance companies are seen as amoral corporations, almost natural phenomenons. You wouldn’t yell at them any more than you would yell at a hurricane. However Americans don’t see government that way. When government does something they don’t like, American tradition is to fight back.

        • Edward Scizorhands says:

          Do you remember the complete shitshow around 10 years ago when it was recommended to reduce breast cancer screenings?

          You don’t have to remember or even know anything about it to predict how people reacted.

          This is partly a cultural issue, because watchful waiting feels like you are being cheated. You aren’t, but getting people to see that is a huge fight. A huge and continuous and ongoing fight.

    • As I understand the situation and the argument …

      Most prostate cancers are the slow version; you will probably die of old age before it kills you. A few are the fast version. Current tests don’t do a good job of distinguishing. So people get a positive result on the test and decide on a treatment that, for most of them, is unnecessary and harmful.

    • Mark V Anderson says:

      Yes I am confused by these changing guidelines. I’ve been reading the whole prostate cancer guidelines with great interest because they directly affect me. I am a 61 year old man. I do generally think that medicine tests too much and is overly cautious, so I am inclined to agree with changing guidelines to test less. Yet I don’t understand these guidelines at all. The PSA test isn’t a great test, because it has lots of false positives, but it is far better than any other non-invasive test. It costs maybe $10-20 for a yearly test. And at my age, I’m getting my blood drawn once a year anyway, for other things, so it isn’t even much of an inconvenience. It sure seems to me that more information is better than less.

      By the way, I have a lot more history on this particular test. I had been getting high PSA results for years, but my doctor was thinking it was false positives because I had a large prostate. But then last year, it increased even more, so I had a biopsy, which is very invasive and hurts. They did find cancer, so I had an operation last December to remove my prostate. Yes, it is a slow growing cancer, so I probably could have lived another 10 years before it killed me. But I am otherwise pretty healthy and plan to live a few more decades, not just one. So I think I did the right thing to have it removed.

  19. Robert Beckman says:

    General medical condition causing depression that I see isn’t tested by psychiatrists today is primary and secondary hypogonadism, especially in middle age men.

    Cause isn’t important, test is for free and total testosterone, and estradiol (not total estrogen).

    Free T under 30, total T under 400 are likely, under half that are probable.
    Estradiol between 10 and 30.

    Treatments are topical or injectable testosterone (ex: Androgel and testosterone cypionate) to increase testosterone, which will also increase estrogen.

    Aromatase inhibitors (ex: anastrozole) to reduce estrogen.

    Comorbidities often present are obesity (bi-directional causation), diabetes (as a result of obesity), and lowered libido.

    (Bad) Side effects at plausibly therapeutic levels of treatment are male pattern baldness.

    Risks are increased prostate cancer growth rate. Studies are mixed, but my best read is that testosterone increases the growth rate, but not the initial presence. Skip the digital rectal exam and get an ultrasound.

    Treatment should start at low and frequent doses, and can’t titrate up to 200mg/day equivalence (this is very rare, if you go above 100mg/day you should have a male reproductive endocrinologist involved as it’s not as simple as testosterone). Effective treatment is often found at weekly injections of 100mg.

    Most endocrinologist aren’t competent to treat this, so a simple referral won’t get what you need. Most male reproductive endocrinologists today are at Men’s Health centers, and don’t accept insurance of any sort.

    • Eric Rall says:

      Seconding this.

      It took me multiple visits to four doctors (two primary care physicians, a psychiatrist, and a urologist who specializes in male hypogonadism) over the better part of two years to get my anxiety and fatigue symptoms correctly diagnosed as secondary hypogonadism and treated with clomid. I’m doing much better now, but I’m frustrated at how long it took to get it sorted out.

  20. Carl Milsted says:

    Which is more dangerous: testing for lead and mercury, or giving Prozac a try?

    If it was a choice between heavy metal testing and doing nothing, then perhaps the conservative thing is not to test. And yes, the bar should be pretty high before removing fillings.

    But is chelating lead out that dangerous if done slowly?

    The citation on fillings was with children with a few. What about the effect of decades of a mouthful of fillings?

  21. LGood says:

    Screening for heavy metals (including lead) is part of my workup for new onset psychosis. It is not part of my workup for depression. In fact, I can’t recall seeing significantly high lead levels in recent years despite having ordered these labs for many patients, which has me questioning why I am still including heavy metals in the workup at all. ‘That’s what I was taught’ is not a great reason to keep doing it. Obviously, the location was contributory to the tale Dr. Dumond tells, and hopefully his discovery has led to some changes in his town. However, I can’t agree with Siderea’s overture/claim that psychiatry in general is blind to the possible physical causes of mental illness. In my practice, I routinely screen for sleep apnea, hypothyroidism, Vitamin D deficiency (living in the far north!), and anemia as causes for/contributors to depression. I regularly order lab work to ensure the general medical health of my patients- often psychiatry may be the only medical provider they actually see. When we are getting into treatment resistance, then appropriate medical decision making has to be used in the attempt to figure out what other biological/environmental/psychosocial issues may be contributory, and if further testing is warranted then we order said testing. This all seems pretty straightforward to me. Honestly, I would much rather find a treatable physical cause any day- that’s easy. I don’t know any psychiatrists who would disagree.

    As far as personal experiences in my practice, I have had quite a few patients with very low Vitamin D, some undiagnosed hypothyroid or borderline hypothyroid, some with other endocrine issues like low T (which may or may not be contributory), many cases of anemia, 2 recent cases of Lyme disease that were diagnosed after coming in for depression.

  22. John Schilling says:

    Reason #812 why it would have been really useful if we could just take a pinprick’s worth of blood in a walk-in clinic and do a full blood panel for everything known to medical science. Granted there’s still nothing you can usefully do about the top quinitle, but it would at least find the 0.0005%-ers that you can do something about.

  23. vnosikov says:

    I live in Chile. Once I came to a psychiatrist and said I am very sad. One of the first things happened was that I was sent to blood and urine testing. I suppose they didn’t test for lead but in the end I got about six pages of results to come with to a next appointment.
    Maybe the attitude towards blood and urine draw as a first step in psychiatry is different in different countries.

  24. RC-cola-and-a-moon-pie says:

    What about genetic tests that purport to identify individualized clues about causes and the efficacy of potential treatments, like Genesight and Genomind? Are these promising avenues for navigating the huge maze of possibilities of this sort, or are they lacking an adequate evidentiary basis?

  25. Confusion says:

    There’s an ‘unless’ missing in

    You insist that nothing can be admitted into the medical canon [unless] it has some guideline-making-body’s stamp of approval, which the guideline-making-body will not give until a bunch of randomized controlled trials have validated every step of the model and [have] shown that the proposed solutions definitely work on a large scale with every demographic of patient.

    (and I think the additional ‘have’ would improve the comprehensibility of this long sentence, but I’m not sure if it is required)

  26. Sigivald says:

    She’s not trying to make small talk – she’s waiting for the one guy who says “I French kiss cockatiels for a living” so she can diagnose him with psittacosis.

    I could have been monetizing that all this time?

  27. Moriwen says:

    I’m sure anecdata is of sharply limited usefulness, but anemia was definitely contributing to my depression, though not by any means causing it; when I noticed my habit of constantly munching on ice and started taking iron supplements, it fixed a general miserable dragging fatigue that was mixing in with, and contributing to, the depression.

  28. dark orchid says:

    The state Department of Public Health’s laboratory tested blood free for anyone under the age of 12 and provided plastic pipettes, finger puncture equipment, and even mailing envelopes at no cost. So, for a while, everyone in the clinic was declared to be under 12 years of age.

    This made me chuckle.

  29. fion says:

    Cortisol? Magnesium balance? The methylation cycle? Cortisol?

    Is it a typo that cortisol appears twice?

  30. Aurel says:

    Children growing up in former communist CEE countries during the 1980s were subjected to horrific amounts of industrial pollution, including extreme levels of prolonged lead exposure. Since lead is theorized to be a primary culprit in exacerbating violent crime, you would assume there would be a sizeable discrepancy in the homicide rate between, say, former East Germany and West Germany, or Western Europe and Eastern Europe as a whole. But the difference in the homicide/violent crime rate is negligible, with many former communist CEE countries having a lower homicide rate than Western Europe. I suspect the same is true when comparing the rate of mental disorders, which is another malady that is supposedly influenced by exposure to high levels of industrial pollution.

    https://object.cato.org/sites/cato.org/files/serials/files/cato-journal/1992/11/cj12n2-2.pdf

    • Gazeboist says:

      Very interesting, but would you mind expand the CEE acronym? I assume it’s “Communist” and then something about “Economy” or “Economic”, but it’s rather mysterious.

    • Doug says:

      I’m not so sure that by the 1980s blood lead levels were that different in the Warsaw bloc than Western Europe:

      > Blood lead levels [in 1994] were generally low in all study areas with geometric means between 39.3 μg/1 and 50.8 μg/l in the western German and between 42.3 μg/1 and 68.1 μg/l in the eastern German study areas.

      https://link.springer.com/article/10.1007/BF00454362

      • dank says:

        Yeah, looking closely at all the linked studies, it seems like the dramatically elevated levels were in areas immediately surrounding industrial processing centers. And the Upper Silesia district referenced in that Cato article actually does have the highest crime rate in Poland.

      • Aurel says:

        It’s hard to find any comparative studies for blood lead levels from the 1980s. I suspect this is mainly due to communists’ general reluctance to disclose instances of societal maladies, especially ones thought to be affected by pollution, a relic of industrial capitalism that was not supposed to exist in a socialist economy.
        There are studies commissioned right after 1989, but keep in mind that many heavy industries began closing soon after the fall of communism, so it’s possible that the East German children in the study you link to, which was conducted in the 1990s, may not have had the same lead exposure as children growing up in the same area during the 1980s. Also, in many of the CEE countries, leaded fuel phase-out was only started in the 1990s, while the United States began its mitigation efforts in the 1970s. (http://documents.worldbank.org/curated/en/753431468750317144/pdf/multi-page.pdf)
        There is also this study from NIH, and while it doesn’t have a true comparative analysis, it does have some interesting anecdotal tidbits: https://ehp.niehs.nih.gov/wp-content/uploads/107/12/ehp.99107a606.pdf

  31. J says:

    What’s your threshold for treating thyroid? My PCP said he doesn’t treat tsh under 5 and that the endocrinologist wouldn’t touch it under 10. I read up and saw that some association of endocrinologists published a recommendation to move it down to like 2 (which I think would put approximately everybody on synthroid), at the same time as another group recommended moving it up to like 10, naturally.

    Anyway, I was as like 4.3 and convinced him to let me try a low dose, and I think it has helped a lot. (I was tired all the time for a year and literally staring at the walls at the worst part. Now the part of my brain that says “let’s do stuff!” is actually working on most days)

    I need to go get it checked again, and was considering checking T at the same time. Good idea/bad idea?

    • Scott Alexander says:

      No hard and fast rules. The more depressed and otherwise-treatment-resistant you are, the more I’m willing to treat marginal thyroid numbers. I’ve seen a couple people like you who didn’t seem like they needed treatment by the official stats, but who improved on Synthroid.

      • J says:

        Any reason I should prefer SSRIs over synthroid? I know SSRIs are pretty benign, but synthroid seems even more so, and more suited to long term use.

        • Garrett says:

          Side note – this is getting into the area of asking for Medical Advice. And that starts to cross legal and ethical lines for a medical professional to respond in a useful way.

          You’ll note that to your original question Scott was willing to describe both the general view of the establishment, as well as his general approach for your condition. But once you start asking about treatment specifics, it enters the realm of Medical Advice. He didn’t even get to sit down and ask you if you french-kiss cockatiels for living!

          • J says:

            Fair enough, good to reinforce the norm that these threads are about science and not individual advice.

            What I’m curious about here is that, eg., “Things that sometimes help if you’re depressed” says:

            Thyroid hormone is very rarely used as an antidepressant augmentation, but there is some preliminary evidence that it is as effective as lithium with fewer side effects, even for people without obvious underlying thyroid problems.

            And I’m wondering why it shows up so late in the flowchart, after 6 months of SSRI/SNRI and next to MAOIs and lithium.

            Sure, it’s also right up front as a thing to check for, but that made me think of it as a binary condition that can be simply ruled out.

            But if its side effects are less severe than SSRIs, and it’s pretty easy to tell when you’ve got too much, then I’m wondering why it isn’t used earlier and more speculatively like the SSRIs are. (Apparently it’s also the #1 most prescribed drug in the US).

            Looks like there’s maybe an increased risk for afib if you squint. And one contraindication would be if there’s depression + anxiety, since overcorrecting on thyroid presents as racing heart rate and overheating. But I’d personally pick that over brain zaps and sexual dysfunction.

            (I mean, the irony is not lost on me that this very post is all about the other 30 things that could cause depression that seem like they should be on the list. I guess my defense is that this one is already on the list and I’m wondering if there are reasons I’m not aware of why it’s not higher up)

        • > overcorrecting on thyroid presents as racing heart rate and overheating

          No, this does not happen reliably. I had those signs when I first raised my thyroid levels rapidly. Later, I got my thyroid levels too high, while looking carefully for those signs and not seeing them.
          I measure and record my heart rate several times a week, and can just barely see a weak connection with my thyroid levels.

    • Yes, improving my thyroid has had important effects on my motivation, and I get the impression that doctors should be more willing to treat thyroid problems.

      Whereas an SSRI seemed wrong – it might have been valuable if my main problem was OCD or if I just needed a vacation from my problems (I tried the SSRI a decade earlier, for reasons unrelated to my reasons for treating my thyroid problems).

      But thyroid problems seem confusing. I partly fixed my thyroid problems by taking ashwagandha. Then I did one or more other things which accidentally made me hyperthyroid, and the process of decreasing my thyroid levels is as unpleasant as having low thyroid levels.

      I seem to have unusually strong thyroid reactions to both ashwagandha and pregnenolone.

      I suspect my thyroid levels had been low due to excess iodine from kelp. It seems like an ideal medical system ought to routinely test for iodine problems, but I’m unsure how accurate current tests are, and they’re not cheap.

      See here for my initial reactions. I’ll have another post on the subject any week now.

  32. Alexandre Z says:

    I like people in Group 4. They know everything that the Group 1 people say. And then they keep an eye on some of the “big idea” Group 3 people. They don’t believe all the big ideas, but they keep those ideas floating around. So when they see a patient, they say “Look. Lexapro is probably the right answer. But if I squint really hard, it kind of looks like maybe the gut microbiome thing might apply to you. Do you want to give that a shot? If so, I’ll look at what Dr. Jo ‘MicroBiome’ Smith recommends and we can try that.”

    That’s pretty much what I look for in my doctors: A good knowledge of what is the RCT-proven way to do things associated with enough knowledge of some maybe-good ideas floating around to look them up when they might make sense to try out.

  33. HeelBearCub says:

    It seems like, from the pulled quotes from Siderea, Scott isn’t actually dealing with the nut of the question, which is basically straw-manning. By constantly using lead as the stand in for the broader question, Scott gets to snarkily argue against one specific thing, as if Siderea was proposing that “lead poisoning is the cause of depression” rather than the broader question of “Why isn’t the field of psychiatry concerned at all with environmental exposure?”.

    Sure, he nods at it a few times, but basically it’s a big side step.

    The answer to that question is perhaps more unsatisfying though. My sense is that we don’t actually know the causes of depression, and therefore we treat the symptoms. That is basically where it seems psychiatry at the clinical level is stuck right now. Psychiatry at the clinical level simply doesn’t care about causes, because at the research level it doesn’t have proof of any causes, nor efficacious treatment for causes.

    • Sniffnoy says:

      By constantly using lead as the stand in for the broader question, Scott gets to snarkily argue against one specific thing, as if Siderea was proposing that “lead poisoning is the cause of depression” rather than the broader question of “Why isn’t the field of psychiatry concerned at all with environmental exposure?”.

      But he does address that point. Lead seems to be basically just an example, really. His answer seems to be, “We do do that, that’s why we ask about your job and such, but beyond that things get difficult.”

      • HeelBearCub says:

        Yes, lead is an example. But it seems to be just an example for Siderea as well. Everything past the initial “we could test everyone for everything but that wouldn’t tell us anything” basically treats Siderea as if they were only arguing for lead screening.

        • wintermute92 says:

          Hmm… As I read this, it was an attempt to cover “environmental exposure” as both an individual and a collective topic.

          As a collective topic, there’s not much you can do – too many things to test for, too little understanding of which ones matter. And as an individual topic, you’re going to be stumbling into issues like the ones with lead screening on each instance. The focus on lead felt like one fully-worked example of the sort of mess you’ll get in to on each specific factor, rather than the whole story.

          • HeelBearCub says:

            Sure. I get that.

            But I still think it ignores the elephant in the room.

            Imagine we asked the question “Why didn’t my primary care provider test me for Niacin poisoning as a potential cause of my Diabetes?”

            The answer to that question is that Niacin poisoning is rare, slightly elevated Niacin levels probably don’t cause insulin resistance, etc. We would only test for that in the absence of other causal factors or some patient history that suggests Niacin poisoning.

            But this simply isn’t possible for depression. We really have no definitive tests at all regarding depression, nor causes. That’s the real issue, and it’s why you can’t describe a differential diagnosis chain that results in testing for X as a possible cause of the depression.

  34. QuaggaSelousi says:

    Antidepressants don’t work for everyone, but it seems clear to me that not only do they work, they work on ~things that aren’t depression~. And I do think that is maybe a problem.

    I spent more than ten years taking various medications and trying a few kinds of therapy. The therapy ranged from neutal to detrimental, but the psychiatrists I saw definitely helped me. They reduced my fatigue, improved my concentration, dulled my anxiety, made me sleep better and cry less and have less pain. I didn’t feel amazing but I was way more functional. Which is not a bad thing.

    Except eventually I couldn’t get out of bed at all, and I finally got dragged to a rheumatologist and diagnosed with an autoimmune disease. When I started immune suppressants it was extremely dramatic how abruptly I felt better on many axes. It was just night and day.

    I’m not saying I was never depressed, but the many years of being told that fatigue, difficulty thinking clearly, and joint pain were symptoms of depression and somaticizing pain didn’t do me any favors, both in terms of being able to realistically evaluate my own experiences and the ability to get non-psychiatrists to look into other explanations.

    I’m not sure at what point, if any, my psychiatrists should have picked up on any of this but the unfalsifiability of being put in the ‘you’re just depressed’ bucket troubles me.

    • cuke says:

      I don’t know about other mental health providers, but at the point someone says joint pain to me, I’m just not willing to conclude “somaticizing.” I’m sure it’s possible for a person to create psychogenic joint pain, but I would venture it’s a more rare thing.

      Joint pain says to me Lyme or other tick-borne disease, some other autoimmune inflammatory cause, sometimes gut parasite or celiac, but definitely not just “depression.” These kind of stories make me mad.

      The number of doctors who translate “I don’t know what’s going on” into “and so your problems are psychosomatic” is amazing to me.

      I’m really glad you got to a doctor who took your symptoms seriously and that you feel better.

  35. jastice01 says:

    My experience is that psychiatrists don’t usually ask for physical symptoms, even though the cost of doing so would be low. Sure that stuffed nose is just a minor annoyance in itself that you wouldn’t bother mentioning when your major issue is constant fatigue, but it might be the hint leading to a chronic sinusitis or allergy diagnosis.

  36. moridinamael says:

    Regarding false positives and “everybody is a little bit weird.” I once told my GP that I would like to run some blood tests for a bunch of things, just to get out in front of any non-obvious health issues. (And maybe explain some of my obvious health issues.) He basically say “no” on the grounds that I would get a bunch of false positives.

    And my response was … so what? I already know I have health problems, and I’m willing to take an 90% shot at having to take extra effort to rule out a false positive in exchange for a 10% shot at discovering an underlying cause for one of those health problems. It shouldn’t even be a debate.

  37. raj says:

    > because the costs outweigh the benefits before then.

    What costs? The financial ones? Shouldn’t this be income adjusted per patient then?

  38. bermudashort says:

    Re: your edit about chronic fatigue and nasal steroids: I’ve been on flonase for sleep apnea for the last 4 years and it is working great. I may switch over to a CPAP machine eventually but this has worked wonders for my life.

  39. hollyluja says:

    for me, iron anemia led straight to panic attacks in both pregnancies, three years apart. It’s the only time I’ve ever had panic attacks before or since. Getting iron IV infusions was an instant cure for me.

  40. lnmaurer says:

    I think that you’ve made a good point that routine lead tests for depression don’t make sense. However, Dumont said that he (and the clinics he has worked at) have never ever done a lead test for any reason whatsoever, regardless of symptoms, period. I guess that I don’t know exactly what falls under the prevue of psychiatry (as opposed to, say, neurology), but if you run into a kid with the symptoms of lead poisoning, wouldn’t it make sense to do a lead test under those circumstances? Maybe kids with symptoms of lead poisoning would never be sent your way (or you would automatically send them to a neurologist if they did), but it seems possible that someone with lead poisoning would be referred to (and treated by) a psychiatrist because lead poisoning can lead to a range of behavioral issues.

    I had some weird behavioral issues when I was really young, and some doctor decided to test me for lead. That turned out not to be the cause (epilepsy, which can lead to behavioral issues in children), but doing a lead test was a wise decision because my symptoms were basically the same as the symptoms for lead poisoning. I think that the doctor who decided to do a lead test was a neurologist, and I find it a little disconcerting that someone with my symptoms would not have been given a lead test if they blundered into seeing a psychiatrist instead of a neurologist (two disciplines that seem to have significant overlap).

  41. Dog says:

    Lead oxide (known as greta or azarcon) is not infrequently used as a folk remedy by Hispanic immigrant populations in the United States. CDC surveys in Los Angeles and Colorado in the 80’s had approximately 10% of families in these populations admitting to the use of lead compounds, with the actual rate of use likely to be higher still. They are typically given to children as a treatment for stomach issues. https://www.cdc.gov/mmwr/preview/mmwrhtml/00000164.htm

    While it may not make sense to test for lead as a general rule, it might be more useful in specific groups like this with known high exposure rates.

  42. pontifex says:

    I feel like we should be doing research on the correlations between environmental contaminants and depression. If the expense and inconvenience of doing blood draws is a problem, we could do random sampling. You roll a D20 and 0 = lead levels test, 1 = mercury levels test, etc. etc.

    At the very least, we could identify communities with specific environmental contaminants. At the most, we might discover some important correlations that would make it into the next set of guidelines. (Or maybe not).

    • Mark V Anderson says:

      Yes, this is what I was thinking. Scott showed why it doesn’t usually make sense do testing for poisons for patients that come in the door with psychiatric symptoms, because they don’t know which symptoms correlate with which causes. What is does make sense is to do research to find out those correlations. I thought there were hundreds or thousands of studies every year on psychiatric issues. Aren’t any of them on finding correlations with psychological symptoms with chemical issues?

      Actually Scott talks abut various studies, but I assume they haven’t found useful results? I am thinking something like if a patient has these specific four symptoms, then that correlates to the same patient having 30% chance of being low in xyz vitamin. If they found such a correlation, then it does make sense to test patients for that vitamin if they have those four symptoms. OF course there are also the possibility that the correlation doesn’t mean causation, such as Scott’s example of poverty causing both vitamin deficiency and the psychological symptoms. But if they aren’t finding actionable correlations with a lot of studies, maybe that means that it is rather rare for a particular poison or lack of vitamin to be the sole cause of the Psych problems. Hopefully with time, some useful testing will be discovered.

  43. juliemadblogger says:

    As an ex-patient/psychiatric survivor I can tell you why psychiatrists don’t bother to do such tests. They want to label everything a mental disorder and if they found out there was some other cause, something valid and simple to remedy, they would lose customers very fast. So they keep patients in the dark and drug them instead. Most depression is solvable if only you stop listening to the typical Cult of Hopelessness that rages throughout the profession.

    Many psych disorders are caused by the psychiatric drugs the patients are given. Electroshock causes cognitive difficulties and memory loss. The last thing any psychiatrist wants to admit is that he/she was the cause of distress in the first place. Psychiatrists and most medical doctors rarely even admit another clinician or institution caused harm. Blame the Patient’s Supposed Mental Illness is the standard. Life might suck but that’s nothing but a symptom.

    Come to think of it, why don’t they do a blood test for depression? Sounds useful, but they can’t. There is none, and there is no chemical imbalance, either. No test that is anything but “just around the corner.”

  44. Jeffery Mewtamer says:

    While I can understand not testing for a specific chemical if only outlier values have any correlation with the given symptoms, I can’t help wondering why a general vitamin/mineral/mineral comtaminant screening isn’t part of the routine blood work attached to a physical or why a psychologist/psychiatrist wouldn’t order such bloodwork in the absence of current records from a patient’s physician.

    I confess I don’t know much about how one would chemically isolate compounds from a complex solution, but I would think it more cost effective to get the entire mineral breakdown of a blood sample compared to measuring a single chemical within the same sample and that that mineral breakdown would say much more about potential risk for any condition related to too much or too little of a substance in a person’s system.

    And if getting the mineral breakdown of a blood sample really is expensive enough to outweigh its usefulness as a general disgnostic/early warning tool, perhaps some medical engineering R&D should be working on a more cost effective way of producing suchc a breakdown.

    I know that, ideally, I’d want to know about any vitamin deficiencies or heavy metal poisoning early enough to correct the issue before it actually makes me sick, and what’s the point of regular physicals if they don’t help prevent illness?

  45. aNeopuritan says:

    “The test is easy – the same simple blood draw that tells you if your cholesterol is too high.”

    … you don’t need to get your asshole fingered anymore?

    [/Brazil]

  46. duncancairncross says:

    Hi Guys
    Lead poisoning testing
    The problem is that the infant brain is much much more fragile when it comes to lead
    The major damage from lead poisoning occurs 0 – 10 years old
    So somebody who has lead poisoning damage may not have high lead levels NOW
    The people who were most damaged by lead in petrol were born between 1955 and 1980

    There is probably no way to “fix” the problem – but is there any way to help somebody with brain damage caused by lead?

  47. Virbie says:

    > I recently had one patient obtain a miraculous and lasting cure of his chronic fatigue using nasal steroids (ie it was apparently caused by nasal inflammation from allergies) but nobody ever talks about that and I’m not sure if it was just a fluke.

    To put another data point in the “not a fluke” column: I had some pretty bad anxiety and depression that I attributed to 1) family history of fairly severe mental illness and 2) a pretty traumatic childhood as a direct result of 1. In the last couple years, I started getting to work on lifelong untreated/neglected minor medical problems that I hadn’t even recognized as medical problems until recently. I started using nasal steroids, strips, and occasional irrigation and every problem I had has just vanished. This includes a variety of minor things that are seemingly unrelated: digestive issues, muscle imbalances/tightness[1], reflux, etc.

    On the occasional unlucky days where my nasal passages close up at night (e.g., I recently had to sleep on the floor in a house full of dogs), many of my symptoms return until I get a good night’s sleep again (though in significantly more minor forms, since I’m not dealing with cumulative poor sleep quality).

    [1] This one is a little bizarre, but I would be so subconsciously exhausted that keeping a proper posture for any significant part of the day was just impossible. Combined with a desk job, this had the long-term effect of making me a kinesiological disaster, which led to a relatively high rate of injury (esp during sports etc).

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