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Hacking the Brain – A New Paradigm in Medicine

The word “paradigm” is over misused and overused, diluting its utility. Thomas Kuhn coined the term in The Structure of Scientific Revolutions to refer to an overarching explanatory system in science. Scientists, according to Kuhn, work within a paradigm during periods of “normal science,” punctuated by occasional “paradigm shifts” when the old explanatory model no longer sufficed, and a radically new explanatory system was required. The term has since come into colloquial use to mean any scientific breakthrough, which marketers quickly overused to refer to just about any new product.

I am therefore cautious about using the term, but I think it is appropriate in this case. In medicine I would consider a new paradigm to be an entirely new approach to some forms of illness. Common treatment paradigms include nutrition, physical therapy, surgery, and pharmacology. A new paradigm is emerging in my field of neurology – directly affecting brain function through electromagnetic stimulation.

The brain is a chemical organ, with many receptors for specific neurotransmitters. This has allowed us to use a pharmacological approach in treating brain disorders – using drugs that are agonists (activators) or antagonists (blockers) of various neurotransmitter receptors, or that affect the production or inactivation of the neurotransmitters themselves. There are limits to this approach, however. First, neurotransmitters are not the only factor affecting brain function. The brain is also a biological organ like any other, and so all the normal physiological factors are in play. Further, there is only so much evolved specificity to the neurotransmitters and their receptors.

If the brain were designed top-down it might have made sense to have each specific function or circuit in the brain use a unique neurotransmitter and a unique receptor. If this were the case, then we could design drugs that would have only one desired effect. But this is not the brain we have. Our brains evolved from the bottom-up, resulting in the use of a few neurotransmitters in various circuits in the brain, with receptors that are related because they are evolutionarily derived from common receptor ancestors. Therefore, when we design a dopamine agonist to treat Parkinson’s disease, they can cause psychotic side effects because similar receptors are used in other parts of the brain.

In some cases we are already pushing up against the limits of specificity to the pharmacological paradigm in neurology. If we are going to have treatments that are dramatically more effective or specific, we need a “paradigm shift.”

Fortunately the brain is also an electrical organ. Neuron firing can be affected by electrical stimulation or magnetic fields. There is no theoretical limit to the specificity of this approach, only practical technological limits. If we could target specific neurons and directly affect their firing, we could have any level of control over brain function.

Using electrical stimulation to affect brain function is actually decades old. The first use of this approach I am aware of is electroconvulsive therapy. In its infancy, this was the crudest of interventions – shocking the whole brain to cause a generalized seizure in order to treat depression. The treatment is effective, but the side effects, including memory loss, were severe. Over the years the technique has been refined, with less and less stimulation to produce the same results.

The cutting edge of “hacking the brain” with direct stimulation is still relatively crude compared to the potential of this approach, but with very promising results. Examples include deep brain stimulation (DBS) for Parkinson’s disease. Wires are placed into specific structures in the brain, the ventral intermediate nucleus of the thalamus, the subthalamic nucleus, or the internal segment of the globus pallidus. Stimulation at specific frequencies can reduce tremors or other motor symptoms of Parkinson’s disease. This is an invasive procedure, and there are side effects, but the results can be very good for patients who are at the limit of what pharmacology can do.

Various types of stimulation, including DBS but also vagal nerve stimulation, are being used to treat epilepsy. Epilepsy might be particularly amenable to this approach, as seizures are, in fact, electrical events.

Transcranial magnetic stimulation (TMS) is another approach – using a magnetic field to disrupt specific brain circuits. TMS is being studied for a variety of applications, including epilepsy and movement disorders, but also migraines, chronic pain, anxiety, post-traumatic stress disorder, and more.

The age of electrically hacking the brain is already here, but what interests me most is the ultimate potential for this approach. Right now there are several technological limitations to this approach: the specificity of targeting smaller and smaller circuits with either external fields or implanted wires, the safety of having wires penetrating the body and entering the brain, powering and cooling implantable devices, and overall computer technology. There is also the knowledge base of which neuroanatomical structures will produce what effects and side effects.

None of these technological challenges will likely prove an absolute limit to this approach, and there is no theoretical limit. We are finding new ways to power and cool small devices. There is plenty of waste energy in a human body – more than enough to power a small, efficient electronic device.

Electronics themselves are advancing at an incredible pace. The promise of carbon nanotube circuits, for example, would use much less power and generate much less waste heat than current electronics. There is also no reason to think that advances in computer technology will not continue at their current pace for the foreseeable future.

It only requires a reasonable extrapolation from current technology and research to imagine a not-too-distant future with implantable computer chips that are capable of targeted machine-brain interface, self-powered and sufficiently cooled, that can alter brain function in precise ways to produce a host of therapeutic effects.

This does raise one other question: are there any theoretical limits to the computer-brain interface? I have discussed this question at length on my other blog, Neurologica. The short answer is that there does not appear to be any significant theoretical limits to such an interface. Brain plasticity seems to allow for a seamless integration of computer and brain, and all the proofs of concept have already been achieved.

Just this week scientists at Harvard reported that they were able to implant a computer chip into the brain of one monkey that allowed it to control the movements of a second sedated monkey (two monkeys were used so that they did not have to paralyze one monkey for the experiment). The implanted chip read the activity of about 100 neurons and learned their activity in relation to physical movements. The second monkey had 36 electrodes implanted in their spinal cord, and when connected the “master” monkey could control the movements of the second sedated monkey.

Conclusion

Opposing pseudoscience in medicine is often a negative endeavor — pointing out that claims are not based upon adequate science or evidence. We have collectively made a conscious effort not to fall into the trap of being naysayers and only focusing on the negative. Science-based medicine is a positive endeavor, promoting good science in medicine. But science itself has a huge negative component: when you separate the wheat from the chaff, you have to discard the chaff.

It is important to occasionally focus on what does work in medicine, and on legitimate scientific advances. Claiming that we are on the threshold of a new paradigm in medicine, one in which we can use a variety of technologies to manipulate brain function to treat a variety of neurological diseases and disorders, may sound like the very kind of hype we generally deconstruct on this blog. This one, however, turns out to be true.

No one can predict exactly how much time it will take to develop specific applications, but the pathway seems clear and we are making steady progress.

Posted in: Neuroscience/Mental Health

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49 thoughts on “Hacking the Brain – A New Paradigm in Medicine

  1. Keating Willcox says:

    1. Focused Ultrasound appears to be a major cure for tremors, a sort of rifle shot at a small portion of brain.

    http://youtu.be/pBLW-nrKWXc
    http://www.insightec.com/Essential_Tremor.html

    2. Psychiatrists continue to use ECT for depression, primarily because it is an easy procedure for insurance companies to pay.

    https://www.madinamerica.com/2014/02/electroshocking-children-stopped/

    Could you explain why such similar therapies have such different outcomes, and why ECT is still around?

    1. windriven says:

      Maybe not a silver bullet yet:

      “Tremor control was optimal early when the lesion size and perilesional edema were maximal and was less later when the perilesional edema had resolved.”

      http://www.ncbi.nlm.nih.gov/pubmed/24371027

      “Psychiatrists continue to use ECT for depression, primarily because it is an easy procedure for insurance companies to pay.”

      Do you have some evidence that ECT is overused because of easy reimbursement or is this intended as an inflammatory allegation? Do you have evidence that ECT is ineffective – or differentially less effective than some other modality for a large segment of the population?

      1. Angora Rabbit says:

        Thanks to you both for the links about ET and stimulation. There are so few tools in the arsenal for this disorder, let alone an understanding of what’s going on, even though it is so common. I can see the appeal of the focused ultrasound over the implants, as the last I’d heard they had limited efficacy, but perhaps this has improved since I last looked. I think this is finally getting attention at NIH and other agencies.

  2. goodnightirene says:

    Where do I sign up to participate in trials? Are we at the level of human trials?

      1. Paul de Boer says:

        Pun intended I presume?

        1. windriven says:

          I should have made it clearer, Paul. Click on it. It is a link to an xkcd comic apropos of the subject :-)

    1. Andrey Pavlov says:

      @GNI:

      Transcranial magnetic stimulation has been used on people for a while. When I was in undergrad we had the device at my institution. My regret is that I never signed up to have it tested on me! It is pretty cool – they could shut down motor cortex or speech or whatever and you’d be moving or talking and suddenly bam! you just can’t anymore.

      Of course, that is because the magnetic field affects the ability for your soul/consciousness to interact with the physical being of your brain…. or that’s what Chopra would claim anyways. ;-)

  3. Eugenie Mielczarek says:

    Thanks for an excellent post on these protocols. One question– are there any negative outcomes for example if a strong magnetic field is used to cure depression– after the application of the field why aren’t some patients left more depressed?

  4. Kevin Moore says:

    here is another paradigm shift in medicine with far-reaching implications for the treatment of a multitude of disorders.

    http://dana.org/Cerebrum/Default.aspx?id=39496

    https://www.youtube.com/watch?v=2EMzInPwDDQ

    1. Kevin – perhaps, but this one is more speculative with less certain results. Manipulating gut bacteria to affect illness is being studied, but has not yielded the clear results that, say, DBS has. So, it’s still too early to tell. This may turn out to be more like anti-oxidants, the real story is more complicated and does not offer an avenue of treating many diseases as was hoped.

      We’ll see.

      1. Kevin Moore says:

        re: “Manipulating gut bacteria to affect illness is being studied, but has not yielded the clear results that, say, DBS has”

        http://www.mayoclinic.org/medical-professionals/clinical-updates/digestive-diseases/quick-inexpensive-90-percent-cure-rate

        1. windriven says:

          The 90% claim is made in the headline but not supported by the copy. Is there a good study to support the claim? It seems to me a perfectly reasonable idea but 90% is a pretty extraordinary claim. If they’re really getting a 90% cure rate it would be interesting to see what their protocol looks like.

            1. Harriet Hall says:

              Everything you have cited is about a single condition: C. difficile infections. One exception does not invalidate Dr. Novella’s general statement.

            2. Andrey Pavlov says:

              As Dr. Hall said, not sure what you are trying to prove here. We accept this as solid science. In fact, I have personally prescribed it for a couple patients in the ICU. It is in no way “another paradigm shift in medicine with far-reaching implications for the treatment of a multitude of disorders.” This is one disorder. And it has literally nothing to do with your original comment!

        2. DB says:

          You can’t claim “far reaching implications” for “a multitude of disorders” then post one news report about one particular condition and assume that your claim is adequately supported.

        3. Andrey Pavlov says:

          I know that for many their brains and their colons are not far removed, but you do realize that there is a difference between claiming a very complex and highly implausible connection between gut flora and cognitive function vs the direct action of microbes on the gut itself, right?

          I mean, you made an assertion about guts and brains being connected by microbiots, Dr. Novella says “that hasn’t really been demonstrated” and your response is fecal transplants in C diff colitis? That is like comparing football to billiards and saying they are the same because they both use balls.

          @windriven: I don’t know about the success rate, but it is very successful. How succesful depends on how well the donor matches up with the recipient. Closer contacts (people that live with you and for longer) will have more and more similar microbiomes in the gut. That increases the likelihood of success. Mayo may be hand picking people to try this on to increase their success rate. Nothing wrong with that – makes perfect sense to do things to people where it has the highest chance of success. But the very fact that taking some random person as a donor has almost no chance of success is very telling in and of itself – it is the complex interplay of the entire microbiome that is at play here and putting random bugs back in isn’t effective. You need to restore the original microbiome as best you can for effect. Which puts the lie to the probiotic drinks that have just one or two species and many times species not at all native to most people’s guts.

          1. Kevin Moore says:

            re” “But the very fact that taking some random person as a donor has almost no chance of success is very telling in and of itself ”

            not according to this study:

            “Two healthy volunteers served as donors and were evaluated for transmissible pathogens”

            ttp://archinte.jamanetwork.com/article.aspx?articleid=1108660

            1. Andrey Pavlov says:

              Fair enough. I was not aware of this data. Seems reasonable so I sit corrected.

              That doesn’t negate anything else Dr. Hall or I have said.

    2. AlisonM says:

      “For every complex problem there is an answer that is clear, simple, and wrong.”

      ― H.L. Mencken

    3. Angora Rabbit says:

      I just heard Ferderico Rey from Jeff Gordon’s lab speak today, and he made the point that everything about microbiome “therapy” except the C. difficile is NOT ready for prime time, not even close, and that includes work coming from Jeff’s lab. And even the C. difficile I think is still working through the FDA process to deal with the surrounding ethical and control issues. I mean, folks really don’t know what they are implanting, truly.

      It’s an interesting enough topic that many folks are starting to work on it, but much of it is merely descriptive and correlative, and very few researchers are doing the drill-down work to sort out which microbe genera are doing what, let alone which species. Definitely not ready for prime time.

      And honestly, it really is easier and better to just eat more fiber and get the same benefits. But that requires a behavioral change, and heaven forfend we ask people to Change their Behavior.

      1. Kevin Moore says:

        Some interesting research has been done on the effect resistant starch has on gut flora. This blog contains links to many studies and comments from people -many diabetic- who have experimented with increasing resistant starch in their diet.

        http://freetheanimal.com/tag/resistant-starch

        1. Angora Rabbit says:

          Hi Kevin, these links are all nice, but they aren’t scientific and they aren’t from the people who are actually doing the microbiota research (crossposting or links on a blog don’t count as actual knowledge). They’re really little more than press releases and personal anecdote. “Freetheanimal” kinda suggests a pre-existing agenda.

          My point is that if a person reads the actual papers in Science, Nature Medicine, et al., – and I know people find this hard to do – one discovers that the press and media are dramatically overselling the results. It’s The New New Syndrome (TM). Even the scientists who are doing the research will tell you that the media and blogs are way overblowing this. That was my point.

          And honestly, the folks doing the “resistant starch” stuff are just (finally) doing what we nutritionists, dietitians, and physicians have been begging them to do for years: clean up their diets and eat sensibly – limit the processed sugar and eat more fiber and complex carbs. I’m glad to learn some folks are finally paying attention.

          1. Kevin Moore says:

            If you look a little closer on the site you’ll see links and discussion of research that goes back 20 years on resistant starch. As far as study results being overblown by the media I see the opposite. Study after study has shown impressive postprandial markers after ingestion of resistant starch, yet most people don’t know what resistant starch is.
            Resistant starch can be quite elusive in the modern diet and they way a foodstuff is processed and handled can mean a difference in resistant starch content by a factor of ten. It is not simply a matter of eating more complex carbs and fiber.

            1. MadisonMD says:

              SInce the links and discussion of ‘Freetheanimal’ cover 20 years of research on resistant starch, perhaps you can peruse them and cite the evidence that supports your assertions that resistant starch is elusive, lost in the handling of foodstuff, and provides health benefits that are superior to other types of fiber.

              Perhaps the most convincing citation for each assertion?

              1. Kevin Moore says:

                wikipedia provides a good primer for those unfamiliar with resistant starch

                http://en.wikipedia.org/wiki/Resistant_starch

                elusiveness of RS
                RS1 is encapsulated such as whole grains and legumes
                RS2 starch granules such as found in raw potatoes(cooking destroys the granules) and green bananas(ripening greatly diminishes resistant starch content)
                RS3 retrograde starch that forms crystals when cooling and or freezing after cooking.
                RS4 manmade Resistant Starch through multiple processes

                You can actually eat a high fiber diet while getting little resistant starch. RS 1 is destroyed through milling, Don’t know anyone who eats raw potatoes or green bananas (RS2) Eating food cold after its been cooked is not especially popular (RS3) and the use of manmade RS4 in the food supply is practically nil.

                resistant starch intakes in the U.S.
                http://www.valemaisalimentos.com.br/material/2.pdf

                some studies

                postprandial and hormonal response
                http://ajcn.nutrition.org/content/60/4/544.short

                plasma glucose and insulin reduction varies with amylose content in bread
                http://cat.inist.fr/?aModele=afficheN&cpsidt=13906522

                High vs. Low RS carbohydrate effects
                p://ajcn.nutrition.org/content/64/6/944.full.pdf

                There a LOT more RS studies out there. The effect that RS has on microbiota seems to be of particular interest now
                http://scholar.google.com/scholar?as_ylo=2013&q=resistant+starch+microbiota&hl=en&as_sdt=0,33

        2. Andrey Pavlov says:

          Kevin, this still has nothing to do with the topic at hand and has nothing to do with a paradigm shift. Angora was much too kind in taking the time to respond so fully.

          1. Angora Rabbit says:

            Replying to Kevin,

            But honestly, resistant starch is still just fiber. Fiber has complex actions in the gut, and these vary with gut region as well as the fiber’s chemical structure. Do you know what fiber is? More traditionally, fiber is any material that enters the large intestine and has biological / physiological effects. Some fiber is digestible (by enteric microbes) and some is not. Some fiber is carbohydrate based (like your resistant starch) and some is not (proteins, sloughed cells, the microbes themselves, undigested or partially digested foodstuffs entering the large intestine). There are lots of different fiber types.

            And pretty much ALL the fiber types have effects on the gut microbiota, by definition. The precise effect and the microbial species affected depends on the fiber type and the fiber’s chemical properties. We are just starting the scratch the surface on this, at least with respect to the microbiotal populations involved.

            So Kevin, your links are nice, but honestly, they cover only a small percentage of what we know about fiber effects and forms. Which is why the experts (like me) caution against the trap of overinterpretation. As your posts inadvertently reveal, the interactions between microbiota, foodstuffs, and physiology are far more complex than is, say, the slice that is influenced by resistant starch (all four flavors).

            1. WilliamLawrenceUtridge says:

              Neat. I thought “fiber” was just indigestible cellulose. Thanks for the expansion. You know what would be amazing? A guest post on the topic.

              But seriously, I love your Goldacre-esque “I think you’ll find it’s a little more complicated than that” approach to all things nutrition. They’re fascinating windows into an incredibly rich area of knowledge.

      2. daedalus2u says:

        Fecal transplants for C. diff are ready (and are desperately needed) for prime time. 14,000 people a year die from C. diff infections. No, it is not as simple as just eating more fiber.

        http://www.nature.com/news/policy-how-to-regulate-faecal-transplants-1.14720

        The microbiome is extremely complicated. Too complicated to fully understand before it can be used to benefit patients.

        There needs to be appropriate regulation, and not the draconian approach that the FDA started to implement at first (treating fecal transplants as a new drug).

        Brain hacking is not a new paradigm (IMO).

        1. Angora Rabbit says:

          Sorry, my comment about fiber wasn’t meant at C.diff. but at some of the other claims. After I posted, I knew someone would misinterpret, and someone did. Me bad for not being clearer.

  5. Frederick says:

    I can’t already Imagine the trolls reading this, Saying “it ‘s already here” That Army already control or brains! lol

    Interesting Article, I have been playing Deus ex Human revolution lately, and I’m a Fan of the new Almost human serie, on fox, Both of those Sci-fi story extrapolate on what New tech could do. Good or bad, and what limit we should put. but, I think they go a little bit to much on the “fear of tech” side of the fence.

    But There a lot of thing that could improve people live, not only people with brain diseases, like Parkinson, but maybe Blind or deaf people. maybe even help people who have some paralysis.
    Al this is Fascinating. Happy that we Have such a Great neurologist as you Dr Novella to keep us inform on new development.

    I hope they built a In-brain Mp3 players ( NOT a Ipod, damn Apple ;-) ) directly wired in the brain audio centre, so i can listen to some RUSH all the time lol

    1. Frederick says:

      First line should read I CAN not can’t. Me and my typo

    2. rork says:

      I’m been waiting for my computer link-up for decades.
      With transmission devices, it would permit “telepathy” too.

      1. Frederick says:

        LOL Cute cats pictures sharing by brain link! AMAZING :-)

  6. William Stewart says:

    For an interesting essay on Thomas Kuhn’s notion of paradigm shift, see the article in the New York Review of Books by Steven Weinberg titled “The Revolution That Didn’t Happen.” It appears that Dr. Novella is justified in his reluctance to use the term “paradigm shift.”

  7. Stephen S. Rodrigues, MD says:

    “Transcranial magnetic stimulation (TMS) is another approach – using a magnetic field to disrupt … epilepsy and movement disorders, but also migraines, chronic pain, anxiety, post-traumatic stress disorder, and more.”

    I did not think yall would be so easily swayed by a study??!! I would have predicted plausible anyway. But we have effective therapies for all the problems except status seizures and movement d/o. Besides why address a problem with one tool? Why not use all the options together?

    But I understand the business of medicine has to look for what is profitable, robotic and used in an assembly line fashion.

    1. windriven says:

      Rodrigues is an intellectual fraud and coward. He uses these pages to peddle his infantile delusions but refuses to confront the fact that modern medicine has changed the human condition in revolutionary ways while the quackery that he advocates only seems to ‘work’ where actual outcomes can’t be objectively measured.

      We do not have “alternative chemistry” or “alternative aeronautics” or “alternative physics” because these delusions have nothing to offer while their non-alternative counterparts have delivered everything from smart phones to supersonic flight. So too the difference between medicine and the quackery that masquerades as “alternative medicine”. I’ve offered Rodrigues untold opportunities to prove me wrong, to humiliate me with the power and majesty of his quackery.

      So far, only the sounds of silence.

      Hey Steve: Look forward to seeing this as a reply to every comment you make from this point forward.

    2. WilliamLawrenceUtridge says:

      I did not think.

      FTFY.

      Why not use all the options together?

      Because each procedure has its own set of risks and benefits, and within intense study to examine how they synergize or interfere with each other, such an approach is potentially dangerous – and good doctors don’t endanger their patients for the New and Sexy.

      But I understand the business of medicine has to look for what is profitable, robotic and used in an assembly line fashion.

      What, like recommending everyone get acupuncture, a treatment modality you just happen to offer (but not shelling out the funds for alcohol wipes to sanitize the skin)?

  8. Stephen H says:

    I for one welcome our new medical implant overlords.

    Closer to home, I would love pain relief that is not opioid in nature, not addictive, does not have all the associated problems of current pain relief, and just does what it does.

    Alternatively, a dopamine agonist that works for me would be good. They are incredibly unreliable.

  9. AlisonM says:

    Thanks for this, Dr. Novella. I knew I was going to have to share this in a couple of places the moment you used the top-down/bottom-up explanation which is so often misused by my science-denying acquaintances. But even beyond your clear explanation of what it means in the brain, this is valuable for explaining one of the reasons why psychiatric medications don’t just fix things – and why this electric signalling approach merits more research.

  10. RobLL says:

    The one person I know who has had DBS had essential tremor, and the limitations were acute and seriously degrading of life quality. Eating, drinking, writing, typing, food preparation, anything requiring hand coordination were greatly impaired. The improvement was dramatic.

  11. Erickttr says:

    One reason the word “paradigm” is mis- and over- used is that the NIH grant application instructions read, “Explain how the application challenges and seeks to shift current research or clinical practice paradigms ,” for the Innovation section. So all NIH is paradigm challenging or shifting… according to the awardees, reviewers, and Program, anyway.

  12. james ainoris says:

    Modern fMRI as well as PET scanning machines have helped map structural and chemical interactions…I was ill and suffered terrible endocrine dysfunction which led to myxedema madness(organic psychosis) etiology stemming from pituitary thyroid hypothalmic axis.. misdiagnosed with mental illness..further studies are needed to possibly lead to curing various types of behavioural disorders.Shalom

    1. Stephen S. Rodrigues, MD says:

      Odd? What was the formal diagnosis?

  13. S.A. says:

    So what you’re saying is that someday I’ll be able to walk into the docs and say, “Doc, I don’t feel good.”. And he will say, “Yes, yes you do.” And I will find myself walking out of his office because a chip in his brain is telling a chip in my brain to feel better and will move my legs until I’m right out of his office. He gets his money and can get to his tee time pronto. I can certainly see the appeal of this technology.

    1. WilliamLawrenceUtridge says:

      Your belittlement of the motivations of doctors aside, it’s of great interest and debate whether the scenario you lay out would be of overall benefit to patients or not. You seem to be implying that having a mechanical or electrical way to “boost mood” or “increase happiness” is somehow a bad thing, that people are better off struggling through their depression to arrive at a new stage of happiness that awaits them if only they can make their way through it. Certainly, this is the plot of many cheerleading books, movies and sitcoms. Man, it would be great if we could all arrive at a guaranteed new level of elightenment and joy after a bit of work and some montages. But the reality is that for some people – this isn’t a reality. In fact, for many. I have friends and family whom simply feel better on antidepressants, whose lives now lack the “hollowed-out middle” while taking SSRIs, and these are people who live vital, interesting lives pursuing careers that interest and challenge them, with close friends and family. For them, such a chip that lacks the side effects of these pills would be a godsend, not the intrapsychic gulag you are portraying them as, not the mere convenience to doctors to make their golf game that you pretend it would be.

      Consider that you are essentially victim-blaming here, that you are saying “if only doctors and patients would work a little harder, then their depression would go away”. Consider how useless, discouraging, condescending and raw-nerve painful this is for patients, and the doctors who care for them, to hear.

      Consider that you are the one ignoring the complexities expressed by Dr. Novella.

      Consider that for some people, the scienario you describe, minus the golf game, would be a suicide-preventing ideal.

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