Scott Alexander examines the problematic nature of emotional support animal letters, highlighting the ethical dilemmas for psychiatrists and the system's shortcomings. Longer summary

Scott Alexander discusses the issue of emotional support animal letters, highlighting the challenges and ethical dilemmas faced by psychiatrists when asked to provide these letters. He explains the legal requirements, the lack of clear evaluation criteria, and the pressure on mental health professionals to approve these requests. The post explores various scenarios and potential responses, ultimately pointing out that the current system creates a form of gatekeeping that favors those who can navigate the process, resulting in a disguised class system. Shorter summary

Scott Alexander argues that schizophrenia should be described as predominantly genetic, addressing counterarguments and emphasizing the importance of this perspective for prevention strategies. Longer summary

Scott Alexander argues that it's fair and accurate to describe schizophrenia as predominantly genetic. He responds to various arguments against this characterization, comparing the situation to how we discuss smoking causing lung cancer. Scott emphasizes that while environmental factors play a role, genetic factors account for the majority of variance in schizophrenia risk. He argues that acknowledging the genetic nature of schizophrenia is important for developing effective prevention strategies, such as polygenic screening, rather than focusing solely on hard-to-control environmental factors. Shorter summary

Scott Alexander examines a study challenging ketamine's effectiveness as an antidepressant, discussing potential confounding factors and maintaining his belief in ketamine's utility despite the study's results. Longer summary

Scott Alexander discusses a recent study on ketamine's effectiveness as an antidepressant when administered during anesthesia. The study found no significant difference between ketamine and placebo groups, challenging previous beliefs about ketamine's antidepressant properties. Scott analyzes the study's methodology and results, pointing out several factors that might have influenced the outcomes, such as the strong placebo effect, the antidepressant properties of anesthetics, and the potential impact of surgery on depression symptoms. He concludes that while the study raises questions, it doesn't completely invalidate previous research showing ketamine's effectiveness, and he maintains his belief in ketamine's potential as an antidepressant for some patients. Shorter summary

Scott Alexander criticizes new DEA regulations that restrict telemedicine prescriptions for controlled substances, arguing they will harm patients and legitimate practices while failing to prevent abuse. Longer summary

Scott Alexander criticizes new DEA regulations that make it harder for telemedicine doctors to prescribe controlled substances. As a telepsychiatrist, he explains how these rules will negatively impact his practice and patients, especially those who rely on controlled substances for conditions like ADHD or anxiety. He argues that the new regulations, while intended to prevent overprescribing, will mainly create inconvenience for legitimate practitioners and patients while doing little to stop actual abusers. Scott outlines the loopholes in the law and how they highlight its absurdity, predicting that these rules will make telemedicine less accessible and effective in the long run. Shorter summary

Scott Alexander argues that a purely biological, apolitical taxonomy of mental disorders is impossible due to ethical and practical considerations that inevitably influence classifications. Longer summary

Scott Alexander discusses the limitations of creating a purely biological, apolitical taxonomy of mental disorders. He argues that such a taxonomy is inherently impossible because the classification of mental disorders is not just a scientific issue, but also a practical and ethical one. Using examples like transgender identity, homosexuality, and pedophilia, he demonstrates how biological similarities can conflict with ethical and practical considerations in classification. The post highlights the tension between scientific accuracy, stigma avoidance, and ensuring access to necessary care. Scott concludes that new taxonomies like HiTOP are still useful, but claims of avoiding political bias in disorder classification are unrealistic. Shorter summary

Scott Alexander answers reader questions on various topics, including his projects, views, and personal preferences in a mailbag format. Longer summary

Scott Alexander responds to several reader questions in a mailbag-style post. He addresses topics such as publishing his book Unsong, the status of his Lorien Psychiatry business, future ACX Grants rounds, his progress on reading Nixonland, his views on AI risk, how to get involved in the rationalist/EA community, Straussian interpretations of his posts, and his refusal to go on podcasts. The responses vary in length and detail, with some providing specific information and others explaining his reasoning or personal preferences. Shorter summary

Scott Alexander analyzes EA's approach to criticism, arguing that specific, targeted critiques are more valuable than vague, paradigmatic ones for driving real change. Longer summary

Scott Alexander discusses the phenomenon of Effective Altruism's (EA) seemingly excessive openness to criticism. He argues that while EA appears to welcome criticism, much of it is paradigmatic and vague, leading to little actionable change. He contrasts this with specific, targeted criticisms that actually challenge individuals and practices, which he believes are more likely to lead to real improvements. Scott uses examples from psychiatry and EA to illustrate his point, suggesting that embracing vague criticisms can lead to inefficiency and a move away from precise, effective practices. He concludes by discussing the nature of paradigm shifts, arguing that they arise from specific anomalies rather than broad, ideological critiques. Shorter summary

Scott Alexander examines the Hearing Voices Movement, discussing its benefits and limitations in treating psychosis while emphasizing the need for a balanced approach to mental health care. Longer summary

Scott Alexander discusses the Hearing Voices Movement, which advocates for treating hallucinations and delusions as normal rather than medicalized. He argues that while the movement has some positive aspects, such as providing community support for people with mild psychosis, it shouldn't be seen as a replacement for medical treatment in severe cases. The post explores the complexities of mental health advocacy, the role of community in treatment, and the importance of balancing different approaches to mental health care. Shorter summary

Scott Alexander provides a comprehensive guide on ketamine as a depression treatment, covering administration methods, effectiveness, safety, dosage, and potential side effects. Longer summary

This post is a comprehensive guide on ketamine as a treatment for depression, covering various aspects such as methods of administration, effectiveness, safety, dosage, and potential side effects. Scott Alexander explains the differences between IV ketamine, esketamine (Spravato), and oral/intranasal ketamine, discussing their relative costs and accessibility. He also delves into ketamine-assisted psychotherapy, the duration of ketamine's effects, and current theories on how it works. The post is written in a FAQ format, aiming to provide thorough and evidence-based information while acknowledging areas of uncertainty in the research. Shorter summary

Scott Alexander investigates the optimal dosage of Lexapro, comparing it to other antidepressants and exploring the reasons behind its effectiveness at lower doses. Longer summary

Scott Alexander explores the question of the right dose for Lexapro (escitalopram), an antidepressant. He examines official recommendations, compares Lexapro to other SSRIs, and investigates why Lexapro might be effective at lower doses. The post delves into studies on antidepressant dosing, the unique properties of Lexapro, and the potential benefits and risks of higher doses. Scott concludes that while there's no strong evidence for high doses of any antidepressant being more effective, prescribing higher doses of Lexapro might be as safe as other SSRIs and potentially more beneficial in some cases. Shorter summary

Scott Alexander critically examines a new theory on antidepressant mechanisms, expressing skepticism while acknowledging its potential significance if proven true. Longer summary

Scott Alexander reviews a recent study proposing a new theory for how antidepressants work, which suggests they bind directly to TrkB receptors rather than acting through serotonin. He explains the study's findings and their potential implications, but expresses skepticism about the theory. Scott outlines several reasons why he finds the new theory unconvincing, including existing evidence supporting the serotonin hypothesis, issues with the study's claims about drug accumulation, and expert opinions on the difficulties of TrkB research. He concludes by stating he will stick with the conventional theory for now, while remaining open to future developments. Shorter summary

Scott Alexander examines a theory proposing that depression, anxiety, and trauma are characterized by low precision of sensory evidence, leading to overreliance on negative priors. Longer summary

Scott Alexander discusses a paper by Van der Bergh et al. that proposes a unified theory of negative emotionality, including depression, anxiety, and trauma. The theory suggests that these conditions are characterized by a processing style that assigns unusually low precision to sensory evidence, leading to an overreliance on negative priors. Scott explores the implications of this theory, including its support for various psychotherapies, somatic therapies, and meditation. He also discusses potential pharmacological interventions and how this model ties together various concepts in psychiatry and predictive processing. Shorter summary

Scott Alexander examines whether psychiatric conditions result from evolutionary failures or tradeoffs, proposing that most disorders involve a combination of both. Longer summary

Scott Alexander explores the nature of psychiatric conditions, discussing whether they result from evolutionary failures or tradeoffs. He presents evidence for both hypotheses, noting that recent research favors the failure hypothesis. However, he argues that some conditions likely involve both failures and tradeoffs. He uses analogies from justice systems and nuclear war scenarios to illustrate how failures and tradeoffs can interact. The post concludes by suggesting that most psychiatric disorders exist on a spectrum from mostly-tradeoff to mostly-failure, and critiques the neurodiversity movement's blanket statements about conditions like autism. Shorter summary

Scott Alexander examines mental disorders through the lens of dynamical systems theory, exploring how this perspective complements and contrasts with taxometric approaches. Longer summary

Scott Alexander explores the concept of mental disorders as dynamical systems with attractor states, contrasting this with the taxometric approach. He uses examples like Alice's health insurance situation and Bob's depression to illustrate how complex systems can have stable states that attract nearby unstable situations. The post discusses how this perspective can help understand the nature of depression and other mental disorders, showing how they can be both dimensional and categorical. Scott also draws parallels between the complexity of mental disorders and the global economy, emphasizing the intricate interconnections and the difficulty of predicting outcomes or effective interventions. Shorter summary

Scott Alexander examines taxometrics in psychiatry, finding that most mental health conditions are dimensional rather than categorical, and discusses the implications for diagnosis and treatment. Longer summary

Scott Alexander explores the concept of taxometrics, which studies whether psychiatric conditions are categorical or dimensional. He explains the difference between categorical distinctions (like humans vs. rabbits) and dimensional variations (like height), and discusses how taxometric methods attempt to determine which psychiatric conditions fall into each category. The post then reviews recent meta-analyses suggesting that most psychiatric conditions are dimensional rather than categorical, contrary to some expectations. Scott reflects on the implications of this for psychiatric diagnosis and treatment, suggesting a move away from binary thinking about mental health conditions. Shorter summary

Scott Alexander describes deleting his blog Slate Star Codex due to a doxxing threat, the aftermath, and his decision to return to blogging under his real name. Longer summary

Scott Alexander recounts his experience of deleting his popular blog Slate Star Codex after the New York Times threatened to reveal his real name. He discusses the reasons behind his decision, the unexpected consequences, and the outpouring of support he received. Scott reflects on the importance of online anonymity and explains his decision to restart his blog under his real name, as well as his plans for the future. Shorter summary

Scott Alexander introduces his new blog, Astral Codex Ten, centered around the concept of ṛta and exploring topics related to rationality, science, and human cognition. Longer summary

Scott Alexander introduces his new blog, Astral Codex Ten, explaining that it focuses on the concept of ṛta, an ancient Sanskrit word related to order, truth, and rationality. He describes the blog's main topics, including reasoning, science, psychiatry, medicine, ethics, genetics, AI, economics, and politics. Scott emphasizes the importance of understanding cognitive biases and how they influence our perceptions and judgments. He mentions his connections to the rationalist and effective altruist communities, as well as his background in psychiatry, and expresses his commitment to fostering an engaged readership. Shorter summary

Scott Alexander deletes his blog Slate Star Codex to prevent the New York Times from revealing his real name, citing professional and safety concerns. Longer summary

Scott Alexander announces the deletion of his blog Slate Star Codex due to a New York Times reporter planning to reveal his real name in an article. He explains his reasons for maintaining pseudonymity, including professional concerns as a psychiatrist and personal safety. Scott expresses hope that the NYT will reconsider their policy, allowing him to restore the blog. He provides alternative platforms for his community and asks supporters to politely contact the NYT about their doxxing policy. The post includes later edits addressing the eventual publication of the NYT article and its negative tone. Shorter summary

Scott Alexander analyzes the PANDA Study, a large real-world antidepressant trial, discussing its methodology, results, and implications for understanding antidepressant efficacy. Longer summary

This post discusses the PANDA (Prescribing ANtiDepressants Appropriately) Study, the largest non-pharma antidepressant trial ever conducted. The study aimed to measure the real-world efficacy of antidepressants, specifically sertraline, in a naturalistic setting. Scott Alexander analyzes the results, which show small to low-medium effect sizes for various depression and anxiety measures. He notes that while the effects are modest, they are not clinically insignificant. The study found that patient-reported improvement had a higher effect size than researcher-measured tests, potentially indicating a disconnect between clinical measures and patient experiences. Scott discusses the implications of these findings for antidepressant efficacy and suggests that targeted treatment approaches might yield better results. Shorter summary

Scott Alexander critiques Bryan Caplan's constraints vs preferences model of mental illness, proposing instead a goals vs urges framework that better explains both mental and physical health issues. Longer summary

Scott Alexander responds to Bryan Caplan's critique of psychiatry, focusing on Caplan's distinction between constraints and preferences in mental illness. Scott argues that this model is flawed and doesn't accurately represent mental or even many physical illnesses. He proposes a more nuanced model based on goals (endorsed preferences) and urges (unendorsed preferences), using examples to show how this better explains behavior in both mental and physical health contexts. Scott concludes that this model allows for a more libertarian approach, supporting individuals in achieving their goals, whether through addressing constraints or managing urges. Shorter summary

Scott Alexander argues that psychiatric diagnoses, while imperfect, are useful tools despite potentially combining multiple conditions with different causes. Longer summary

Scott Alexander discusses the criticism that psychiatric conditions like autism or depression are not unitary categories but rather collections of different conditions with different causes. He argues that this view, while correct, is not as revolutionary as some think and doesn't invalidate the usefulness of these diagnoses. Scott compares psychiatric conditions to medical conditions like pulmonary edema or stroke, which can have multiple causes but are still useful diagnostic categories. He suggests that psychiatric disorders might ultimately be understood as computational conditions, with various biological, psychological, and environmental factors affecting the brain's computational parameters. The post emphasizes that while research into subtypes of conditions like depression hasn't been very productive, current psychiatric diagnoses remain the most useful tool available, despite their limitations. Shorter summary

Scott Alexander reviews 'The Body Keeps The Score', a book on PTSD, praising its historical context but criticizing its outdated science and uncritical embrace of alternative therapies. Longer summary

Scott Alexander reviews 'The Body Keeps The Score', a book about post-traumatic stress disorder (PTSD) by Bessel van der Kolk. The review covers the book's historical context, its insights into PTSD symptoms and neurobiology, and its treatment recommendations. Scott praises the historical accounts of PTSD recognition but criticizes the book's outdated scientific claims, lack of consideration for genetic factors, and uncritical enthusiasm for alternative therapies. He notes the book's emphasis on bodily disconnection in PTSD patients and the importance of reconnecting with the body in treatment. Overall, Scott finds the book less helpful than expected for guiding clinical practice, but acknowledges its potential value in highlighting the importance of trauma screening and specialized trauma clinics. Shorter summary

Scott Alexander clarifies his intentions behind the APA photo-essay and cautions against overly negative interpretations of psychiatry or any professional field based on selective criticism. Longer summary

Scott Alexander addresses the unexpected negative reactions to his previous APA photo-essay, which was intended as a lighthearted critique rather than a condemnation of psychiatry. He draws parallels between the tech industry and psychiatry, noting how both can be unfairly portrayed through selective reporting of their worst aspects. Scott emphasizes that while there are issues in psychiatry, the field also includes many dedicated professionals doing important work. He encourages readers to be skeptical of overly critical portrayals of any field, including his own writings, invoking the concept of Gell-Mann Amnesia. Shorter summary

Scott Alexander humorously describes his observations at the American Psychiatric Association meeting, highlighting pharmaceutical influence, social justice focus, and historical context of psychiatry. Longer summary

Scott Alexander attends the American Psychiatric Association meeting and shares his observations in a humorous photo-essay. He notes the overwhelming presence of pharmaceutical advertising, the conference's focus on social justice issues, the presence of Scientology protesters and CIA recruiters, and the abundance of new but seemingly unnecessary psychiatric drugs. He reflects on the historical context of psychiatry, including its past political biases and progress over time, while critiquing the current state of the field and its relationship with drug companies and social trends. Shorter summary

Scott Alexander presents a case for skepticism about psychedelic therapy in psychiatry, outlining seven points of concern while still supporting further research. Longer summary

Scott Alexander discusses reasons for skepticism about the potential of psychedelic therapy in psychiatry. He outlines seven main points of concern: small studies by enthusiasts leading to unreplicable results, the tendency for all psychotherapies to have amazing success stories, comparison with ketamine's underwhelming results, the case of NSI-189 which failed in trials despite anecdotal success, the lack of obvious effects given widespread psychedelic use, the possibility that insights from psychedelics are illusory, and potential FDA restrictions limiting access and effectiveness. Despite these concerns, Scott supports psychedelic research and hopes to be proven wrong. Shorter summary