After three months of closure, my gym in Vancouver re-opened on June 1st. Even though I’ve been a gym rat since 2013, the pandemic took a huge toll on my physical performance. Six weeks later, my workout capacity hovers around 40% of what it once was.

I see this deficit most clearly on an indoor rowing machine. The treadmill of canoes, rowing machines produce resistance thanks to air flowing through a flywheel. The wheel connects to a chain, and the combination of pushing with your legs and pulling the chain handle spins the flywheel. The faster you row, the faster the flywheel spins and the more resistance it creates. The amount of power you produce — measured in meters, calories, or watts — is displayed on a small screen, giving you instant feedback on each stroke.

Two ways to get the flywheel moving: brute strength or proper technique. In the past, I could muscle my way through at a reasonably respectable pace for someone built for ballet, not rowing. But thanks to a combination of three months off, nagging injuries, mid-thirties hormones, elevated base level stress, and extra glasses of pandemic wine, I have been forced to adjust my strategy. Pulling the handle like all hell just doesn’t work anymore.

Like most things that seem simple, rowing technique is complicated. Arms straight. Head neutral. Shins vertical. Heels lift. Push through the legs, then extend through the hips, then pull the chain. Legs, hips, pull, release, hips, legs. Don’t let the chain slack. Don’t hunch. Don’t lead with the back. Don’t bend the arms too early. Legs, hips, pull, release, hips, legs. Breathe. Legs, hips, pull, release, hips, legs. Repeat.

My goal is not to become a professional rower. It’s to get through the rowing portion of my afternoon workout so I can move onto the next movement. Focusing on every aspect of my rowing technique would be a waste of my time. Instead, I focus on one thing I can do to increase my efficiency: get the handle to the proper starting position, every stroke, every time. Focusing on the handle’s placement guarantees that 1) my stroke length will be as long as possible, which increases speed; 2) positions my back and legs to fire in the right order at the right time, which increases power; 3) keeps my mind zeroed in on one thing rather than 100 things, and 4) distracts me from how awful rowing is.

Why is this relevant to happiness? Because by focusing on one aspect of rowing technique, my power and speed are guaranteed to increase, thereby improving my overall performance. I don’t need to be great everywhere all the time. I just need to be a little bit better, repeatedly. Over time, this will translate into more strength and stamina…without breaking my spirit.

The same theory applies to happiness. It’s not about making sweeping changes and overwhelming the system with hundreds of new processes, only to beat ourselves up for failure. It’s about taking stock of your life and focusing on doing one thing right, every time that will set a stronger foundation for each process that follows.

For me, that one thing is staying off social media. Maintaining that boundary gives me greater emotional and psychological resilience, which means I am able to consume more meaningful information, brush off minor irritations, and more quickly bounce back from major roadblocks.

For my sleep-challenged partner, Justin, that one thing is making sure that he dims the lights in the apartment at least an hour before getting in bed. Keeping the lights down and the candles lit sets him up for a better night’s sleep, which means every aspect of the next day gets easier.

For my mother, that one thing is keeping the house clean. But instead of doing a big clean up once a week and then getting irritated as the week moves on and the mess piles up, she commits to tidying up two things every time she walks in a room. The result? The house is always well kept — in no time at all.

What is one thing in your life, when done right every time, that makes your day easier and lighter? Find it. Focus on it. Do it right. Every time.

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How to Be Great? Just Be Good, Repeatably — blog.stephsmith.io

To create something great, we are told to take baby steps, put one foot in front of other, and take it one day at a time. We’ve heard these platitudes our entire life, but in the moment it can be hard to see how small changes add up to something bigger. We want to be great, now. In this piece, Steph Smith shows us that greatness is a myth. To be great, she argues, just be good enough…over and over and over again.

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Jim Collins – Concepts – The Flywheel Effect

Jim Collins is a researcher focused on business management and sustainability. This excerpt, from his book Good to Great, highlights “the flywheel effect,” which states that in any great creation, there is no single defining action that leads to success. Instead, it is about making relentless, incremental progress until the flywheel gains enough momentum to turn on its own.

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The secret to giving a compliment that makes people glow | — ideas.ted.com

Struggling to find that one thing to do right each day? Try giving one person per day a heartfelt compliment. Educator and TEDx speaker, Cheryl Ferguson, shares how.

Summer months in Vancouver mean endless hours of daylight. At its peak, light emerges around 4 am and does not wane until well past 10 pm. Earplugs, sleep masks, and blackout shades are the only defense against a bungled circadian rhythm, and some mornings—like this morning—it’s particularly hard to get moving.

I stumbled out of bed before 7am, a sliver of sunlight streaming through our northern facing apartment. I sat in silence for 11 minutes, my usual meditation, and found myself on the edge of dozing off. The gong signaling the end of my mediation sounded, and I wrapped myself in a blanket and took a morning snooze on the couch.

When I mustered the will to peel myself off the cushions, fuel myself with tea, and transform the bedroom from my sleeping place to my coronavirus office space, I opened up The Daily Stoic to read the day’s entry:

“On those mornings you struggle with getting up, keep this thought in mind—I am awakening to the work of a human being. Why then am I annoyed that I am going to do what I’m made for, the very things for which I was put into this world? Or was I made for this, to snuggle under the covers and keep warm? It’s so pleasurable. Where you then made for pleasure? In short, to be coddled or to exert yourself?”

-Marcus Aurelius, Meditations, 5.1

I am awakening to the work of a human being. Aurelius seemed to interpret this awakening literally. He was a Roman emperor, and the demands of the job required the occasional morning pump up. I imagine that woven silk sheets of the imperial palace were significantly more pleasurable than managing 1st century Rome, but as Aurelius said, he was put on Earth to run Roman empire, not whittle the day away in bed. What choice did he have?

But in July of 2020, I am awakening to the work of a human being takes on a whole new meaning. To simply be human is the work. It is all there is and all there ever will be. Six months ago our work was our career, our success, our routine. But when it was all taken away, the real human work remained. The job, the schedule, the life—it’s nothing but a thin coat of paint.

What is the real human work that you were born to do? If you have trouble answering, look issues that have roared their ugly head over the past few months. What makes you angry? What are your patterns? What challenges has the pandemic revealed? And what gifts has it given you? What changes will you take with you?

Get clear on the work ahead, and know that it will not be easy. Deep work never is. But you will be doing the work you were made to for, the very thing for which you were put into this world. Are going to remain coddled? Or wake up, face the day, and get going?

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If You Want to Change the World, Start Off by Making Your Bed – William McRaven, US Navy Admiral — www.youtube.com

I first watched this speech around 2010, after nearly 25 years of refusing to make a bed that I figured I was destined to mess up that night. Since I first watched it, not a day has passed where I haven’t made the bed. Why? Little things matter. And starting the day with one completed task, sets you up to complete the rest.

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BBC – Travel – The unexpected philosophy Icelanders live by — www.bbc.com

Icelandic people know they are not in control; their world is made up of volcanos, bitter cold, and endless nights. Living with the force of nature dwarfs wee human life, leading to the Icelandic phrase,‘þetta reddast’, which roughly translates to the idea that everything will work out all right in the end.

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The Biggest Psychological Experiment in History Is Running Now – Scientific American — www.scientificamerican.com

DISCLAIMER: If you’re exhausted from covid content and/or someone who is easily riled up from covid content, skip this article. But if you’ve got the capacity, glaze over the usual covid terribleness and read this piece through the lens of ‘real human work.’ One line that stands out: “People who believe they can cope do, in fact, tend to cope better.”

Yesterday, I was listening to a podcast with renowned couple’s therapist Esther Perel. She was talking about how couples were coping with the pandemic and said, “You can’t be feeling great in this moment. You can feel relieved. You can feel thankful. You can feel appreciative for what you have. You can feel humble. You can feel thankful to things, but you can’t feel great in this moment, because if you’re feeling great in this moment, you’re detached, you’re disconnected.”

The episode was recorded sometime in late March/early April, about three weeks into lockdown. Had I listened to it at the time, I likely would have agreed. How could someone feel great when the world was but an ominous shell of itself, with an air of fear and uncertainty thick enough to choke even the healthiest of lungs?

But in listening to Perel’s comment now, three months later, my thoughts on the matter are different. Why can’t we strive to feel great in this moment? And why are we encouraged to exchange our own well-being in order to stay plugged in to global suffering?

Because it’s important to stay informed. Because ignorance is dangerous. Because a good person cares about other people. Because it’s selfish to look out for number one. Because the world doesn’t revolve around you. Because people are dying. Because. Because. Because.

Happiness is a most rebellious act. To be happy, especially when others are not, is to break an unspoken human rule that equates thriving with selfishness. The Australians call this Tall Poppy Syndrome, referring to the expectation that a field of poppies should grow together. If one grows too tall, it needs to be cut down. In human terms, this means we celebrate the downfall of high achievers and shun those with enviable qualities. Poppies that stand out for doing well don’t fare much better than those that stand out for doing poorly.

But I feel guilty for being happy when so many people are hurting.

To tear down others for perceived happiness is a fundamental misunderstanding of happiness in the first place. It assumes that happy is a destination rather than a state of existence, and that choosing personal happiness is a callous blow to collective suffering. It is the guilt, not happiness, that emerges as the most selfish act. Guilt is what happens when we take someone else’s pain and make it about ourselves. It does nothing subtract pain, and instead doubles its existence while taking focus away from the issue at hand.

Think about it. How do you feel after a day when you’ve been wracked by guilt or have spent too many hours following the latest on infection rates or political incompetence or unrest? Are you left with the emotional capacity to answer the phone when a distressed friend wants to talk? How do you respond when your kid knocks over an heirloom and shatters it on the floor? What vice to you choose to numb the pain you just witnessed? How does any of this help you and the people around you?

But by pushing guilt aside and allowing ourselves to learn happiness—or strive for greatness—even in a time of anguish, we actually expand our capacity to help others who are suffering. We are able to more freely move between contentment and action, without getting tangled up in a collective web of pain.

So grow tall, break the rules, rebel with happiness. The world may not understand you, but now more than ever, it needs you.

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Viktor Frankl on the Human Search for Meaning — www.brainpickings.org

The Australian psychiatrist and Holocaust survivor said of his experience in Auschwitz: “Everything can be taken from a man but one thing: the last of the human freedoms — to choose one’s attitude in any given set of circumstances, to choose one’s own way.”

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Consciousness Isn’t Self-Centered – Issue 82: Panpsychism – Nautilus — nautil.us

Humanity has convinced itself that consciousness is an inherently human trait. But what if it isn’t? This is a fascinating read that focuses on the scientific search to determine all things—plants, stones, a fork—have consciousness.

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Dealing with the guilt of privilege — www.rappler.com

I love the last line from this excerpt:

“The guilt that many have begun experiencing in this pandemic may be attributed to increased self-awareness of their advantaged position. As with any emotion, the feeling of guilt is valid and normal in light of a realization like this, but it is just as important to realize that being privileged, in itself, is not wrong. Privilege is often something that is given, not something that is chosen. However, what can be chosen is what to do with privilege.”

No matter what country we live in, what culture we’re a part of, or what religion we practice, everything in our world revolves around a single goal: attaining happiness.

This far-off-but-acheivable-if-you-follow-the-rules happiness is our own personal autocrat. In a capitalist society, the happiness dictator demands that if we study hard to gain a career, we can work hard to earn money to buy things that make us happy. In a communist society, the happiness dictator demands that if we all work hard to produce enough to share then everyone will be equally happy. Meanwhile, a Catholic happiness dictator tells us that if we follow the word of the Bible and repent for our sins, we will hit the happy lottery and win a one way ticket to heaven.

It’s all a rat race to nowhere. A new iPad won’t bring lasting happiness any more than having the same amount of potatoes as your neighbor or confessing to a stranger in a box. And still, we follow the rules of these mythical ideas because somewhere out there, just out of our reach, is the happiness we’re promised.

Happiness is a paradox. The more we look for it, the more we become aware that we don’t have it. And when we’re asked to define what happiness is and why we want it, the answer is unclear. Is happiness just the absence of pain? Satisfaction? Having hope? Experiencing love? To want for nothing?

The Dutch do a better job of breaking down happiness into meaningful definitions. Lykke is the Danish word for sort of elusive feeling we search for, the sort of deep happiness that comes only once in a while but feels so good. It is inherently fleeting and often out of our control. Glad is more of a nothing-out-of-the-ordinary contentment, or general satisfaction with the trajectory of one’s life.

(In my view, lykke is a feeling and glad is a state, which means this newsletter should really be titled, “Glad is a Skill, Lykke is a Bonus.”)

According to Buddhism, most people identify happiness with pleasant feelings, and all of life is a quest to feel more pleasure. The problem, though, is that feelings are fickle. We experience joy, then we are dissatisfied when joy dissipates, which leads to malaise, which prompts us to search for joy again. We rinse and repeat this cycle, never gaining any meaningful last effects and constantly subjecting suffering for it. Hence the Buddhist mantra, “Life is suffering.”

Buddhism argues that the only way to relieve this suffering is to understand the impermanent nature of all feelings which leads us to stop craving happiness. To truly understand that all feelings come and go—satisfaction, boredom, anger, panic, joy, malaise—is the whole point of mediation.

Some people get this concept more than others. They’re the ones who seem to shrug it all off and keep on whistling. Then there’s the rest of us, myself included. I have to put in work to recognize that not only am I in a constant state of craving, but that I am actively convincing myself I can hold onto more happiness if I can just change something out there. But I have also touched on a handful of moments—typically in meditation or walking in nature—where I tap into a state of being that demands nothing from the world around me. In those moments, I know I have everything I need and that who I am is not the home I live in or the job I do or how I feel about the things I have. Gratitude and lykke rush through me and out of me, leaving a hum of glad with no external attachment.

These moments are transient. I am in no way a master of remaining in this state, but they remind me that it is possible stop all the wanting and simply just be.

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The money, job, marriage myth: are you happy yet? | Books | The Guardian

One of the biggest issues I’m currently working on is untangling the idea that money and jobs with prestige and praise = success. This article helped unravel some of my mental knots; 87% of florists say they’re happy compared to 64% of lawyers, and the happiest people work 21 – 30 hours a week.

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Why Finland And Denmark Are Happier Than The U.S. — www.youtube.com

What does it take to be happy? The Nordic countries seem to have it all figured out. About those high taxes: When paying hefty tariffs means it costs only $300 to have a baby, homelessness is nearly eradicated, and the government will support you while you quit your day job and go to art school…well, it seems people are more than happy to shell out.

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The Key to Finding Happiness: Stop Trying to Be Happy | Mark Manson — markmanson.net

Though they seem at odds, Manson’s call to stop trying to be happy aligns exactly with my theory of happiness as a skill. Happiness, he says, is not something you achieve. It’s the side effect, rather, of getting your life in order.

On March 14 and June 14, my partner Justin and I marked the beginning and end of Vancouver’s coronavirus lockdown in the exact same way: we met friends at our favorite bar around the corner from our apartment. All things considered, Vancouver has fared exceptionally well throughout the pandemic. Our restrictions never reached draconian levels, and yet our infection rates still sit squarely at the bottom of a list that includes both North America and Europe.

Still, dissension surrounding shutdown and reopening rumbles in the background. Throw the Black Lives Matter protests into the already precarious social dynamic and it feels like everyone is walking on societal eggshells. Even as I type this, my heart rate is ticking up. I’m afraid of saying the wrong thing, of being judged for saying too much or not enough, of being callous and creating more pain.

I am reminded of how this instinct to shut up and pull back stymies any chance of meaningful growth and discourse. At the bar the other day, we ran into our friends’ neighbor, Martino, and invited him to join our table. Martino is a 32 year old Brazilian lawyer in the middle of divorcing his Canadian wife. Like most of the Brazilians I’ve met in my life, he blew right past small talk and got to the good stuff. He asked Justin and me if we were going to have kids (no), if our Cambodian and half-Chinese friends at the table had ever experienced racism in Vancouver (yes), and whether or not it was sexist to admit that being out of work made him feel like less of a man (while it aligns with conventional notions of masculinity, we determined that it was not inherently sexist.)

Martino said he spent most of his life in a racist, homophobic, misogynist, and deeply Catholic part of Brazil. It wasn’t until he arrived in Vancouver that he was forced to expand his mind, face his built-in prejudices, and learn. But what struck me most about our conversation with him was his willingness to be honest and open—to mere acquaintances—about where he was in his journey.

He said in heavily accented English, “I’ve grown so much here. Canada has taught me to accept different races and homosexuality. But I am still learning. I have trouble accepting the transgender people. I don’t understand, but I want to learn. And I want to understand. Can you help me understand?”

Here’s the kicker: Martino said this in the presence of three University professors. One studies racism and refugees in South Asia, one studies social justice and with a focus on sexuality and queer theory, and Justin is a political scientist. In short, Martino was tangoing with precarious partners. These people exist in a vacuum of political correctness, constantly having to curate their actions in order to keep from pissing off students who could bring down their careers with a single accusation. It creates a bizarre paradox of elitism and power that forces them to monitor everything they say while also putting them in a position of authority. They all sat there, taken aback by Martino’s forwardness, and contemplated appropriate answers.

Meanwhile, I sipped my drink with a shit eating grin on my face because it was so refreshing to hear someone cut through the bullshit and own up without claiming to have it all figured out. Because deep down, we all know we have built in bias. Class. Politics. Race. Education. Age. Body size. Dietary choices. Few among us can say that we’re truly blind to our differences.

So what does this have to do with learning happiness?

Depression, I believe, occurs when there is a great distance between our outer lives and inner selves. When we are forced to show up in the world in a way that is not congruent to who we are, it results in festering melancholy. This reactionary, pick-a-side, eggshell society leaves little room for people to grown and evolve on any reasonable timeline. Without the freedom to be wrong, to admit ignorance, or to stand strong in opposition to the status quo, we present an outer self that does not match our inner self, inevitably bringing depression a heaping helping of its favorite fuel—shame and guilt.

I am no saint. I know I’ve got my own sticking points, and even after witnessing Martino’s admission of his own, I’m still not ready to admit mine to an untested crowd. The fear is buried deep. I’m afraid of saying the wrong thing. Of being judged for saying too much or not enough. Of being callous and creating more pain.

And so I wonder, how might we relate to each other if everyone felt free to own up to their prejudices and limitations? How might we be able help each other heal? How much faster could we grow if we knew we wouldn’t be punished for asking how? And what does it mean for our happiness, if we remain too scared to say nothing at all?

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Jon Stewart Is Back to Weigh In – The New York Times — www.nytimes.com

If there is one article you read this week, make it this. Jon Stewart covers everything—media as entertainment, covid, partisanship, BLM—and like always, he says what I imagine many of us are thinking but don’t have the balls (or wit) to say. An excerpt:

“If you say, ‘I know people whom I love who voted for Trump,’ people will be like, ‘[Expletive] you.’ I go, ‘I don’t think they’re racist.’ ‘They are racist, and if they’re not racist, they’re passively participating in a racist system.’ So am I. So are you. We all are. Have your lines in the sand, but understand: Do you have a phone? There are probably things in the way that your phone is made that are not the greatest in terms of workers’ rights. We all have [expletive] on us. Approaching it in that manner is not both-siderism, and it’s not asking for civility.”

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Dolly Chugh: How to let go of being a “good” person — and become a better person | TED Talk — www.ted.com
What if your attachment to being a “good” person is holding you back from actually becoming a better person? In this accessible talk, social psychologist Dolly Chugh explains the puzzling psychology of ethical behavior — like why it’s hard to spot your biases and acknowledge mistakes — and shows how the path to becoming better starts with owning your mistakes. “In every other part of our lives, we give ourselves room to grow — except in this one, where it matters most,” Chugh says.

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The Lifespan of a Thought Experiment: Do We Still Need the Trolley Problem? – The Atlantic — www.theatlantic.com

You know the ‘trolley problem.’ You’re driving a trolley and heading toward five people. One person stands on the tracks off to the left. You have a choice: pull the lever, veer left, and be responsible for killing one. Or you can do nothing, stay on the path, and kill five. Which do you choose? Which choice is the ‘good’ choice?

If 2020 had a slogan, it would be “21st century trolley problems.” Quarantine vs. herd immunity, to reopen or stay shut, to protest or not to protest. All have consequences, and no one truly wins. Are we good or are we bad? Does it matter?

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Are You a Good Person? – The New York Times — www.nytimes.com

Seven experts answer the question, “What makes someone a good person?”

The following was originally published in my newsletter, Happiness Is A Skill, Issue #01. 

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The past few months have gifted us with an opportunity for deep reflection. While the world changes at a breakneck pace, we’ve all been stuck inside, left with nothing but the life we’ve created for ourselves and the emotions that come with facing it.

Turning inward has forced me to take a hard look at how I want to move forward, both in my personal life and public one. Between winning Chopped and having an impactful mental-health piece published in the Washington Post, I’ve turned into the world’s most wee public figure. With my memoir on antidepressant withdrawal now out for submission (which means publishers are considering whether or not they want to buy the manuscript and publish the book), I put myself under considerable pressure to produce on social media in order to tantalize publishers.

The problem, though, is that social media is notoriously awful for mental and emotional health. After four years of doing the deep work to get myself off of antidepressants and out of a decade and a half of depression, three weeks of Twitter sent me back into psychological hell. About 10 days ago, I broke. Social media is simply filled with more pain than I am currently able to carry on my shoulders, and I made the choice to step away. The apps are off my phone, blocked on my computer, and I’m turning to print (gasp!) for news.

Our society is filled with all sorts of viruses. Biological, political, racial, cultural, systematic—they all seep into our cells, etching themselves into our physical and emotional makeup. Unplugging from social media may seem nuclear, but consciously and constantly exposing myself to other people’s pain—which I can neither fix nor control—is the emotional equivalent of licking a bathroom stall at LAX. Why do that to myself? Who benefits from making myself sick? Not me. Not you. Not my community.

I believe that happiness is a skill that must be learned, practiced, and maintained. We aren’t born with it any more than we’re born with the ability to run a marathon or complete a PhD. Some of us may come in with runner’s legs or photographic memories, but the mere presence of aptitude does not guarantee success. The work is the work. In continuing to put myself in the line of social media fire, I was consciously working against the happiness practice I built. And I refuse to do it any longer.

Instead, I am funneling my former social media efforts into a new newsletter dedicated to helping people who want to wean off their antidepressants, recover from depression, and learn the skill of happiness. You can expect everything from relevant articles to inspiring figures to actionable practices to musings on Stoic philosophy. Some weeks may make you laugh, others may make you think. All of it is designed for people who are ready to do the work.

So many of you have stuck with me for so long. Know that I appreciate you, and I hope that each week it brings a little extra value to your life…without the toxicity that comes with so much of the internet. In this space, you won’t find any ads for toenail fungus cream, political bloodbaths, or cruelty. Just little morsels of strength and light in an otherwise dark world.

It’s hard to celebrate anything right now. Yesterday, after a much needed few days entirely off the grid, I came back to a digital shitstorm. The specifics are irrelevant, but what was important was that in the middle of getting real mad and doing a whole hell of a lot of ugly crying, I realized I was having a moment of clarity. After months of fighting to get my work heard, I’d finally hit the end of my rope. I was done.

The exact words out of my mouth were, “I don’t know what this means moving forward, but I refuse to keep doing this to myself.”

It took an accident of an event for me to surrender, but understanding what was happening took a boatload of self-awareness. In order to recognize that I needed to make a change, I had to trust in myself to:

I didn’t develop any of these skills in the past 24 hours. They are all a result of hard, deep self-work I’ve put in over the past 4 years. Had I not spent those years actively cultivating these skills, I would have melted down yesterday without recognizing the value of the meltdown. Anger, tears, emotion—it’s all a bright flashing sign pointing to an issue that needs to be fixed. And yet we never teach people to recognize an emotion as such, and so we end up in a feedback loop of our own personal hell.

Happiness is not a given. Nor is it doled out to some but not others. It is something that must be cultivated and learned through trial and error. When you’re depressed or struggling though, it can be impossible to think you can help yourself. I know that during my 15 years of depression and year of antidepressant withdrawal, every time someone suggested a gratitude journal, I wanted to punch them in the face. Gratitude works when you want life. It mocks you when you want death.

My goal is to teach people the skills that I’ve learned so that they can take control of their own life. After yesterday’s moment of clarity, I’ve realized that I have to try a different strategy. What I was doing simply wasn’t working for me. It had me working against my own ethos, and that is a recipe for malcontent. The good of others is no good if it’s not good for me, too.

And so I move forward, my way, this time.

“Iatrogenic comorbidity” is one of those jargon phrases that makes me want to run far far away from research.  To me, it’s code for this is an article for those who have letters after their name and if you don’t you’re too plebian to understand. For regular folk, it’s a term that’s difficult to remember, impossible to pronounce, and seems to have something to do with death.

It has nothing to do with death. In layman’s terms, iatrogenic comorbidity is illness or disease caused by medical treatment which results in two or more simultaneous conditions in a patient. It is also one of the most important (and overlooked) aspects of treating depression and prescribing antidepressants. If more patients understood what it meant, perhaps more doctors would be forced to take it into consideration.

Iatrogenic is an adjective that means, “relating to illness caused by medical treatment or examination.” For example, if a woman has heart surgery and the stitches get infected, the infection is an iatrogenic effect. If the stitches never existed, she wouldn’t have an infection.

Comorbidity means the “simultaneous presence of two or more chronic diseases or conditions in a patient.” For example, an elderly person could have osteoporosis (brittle, porous bones) and dementia at the same time.

Putting the two words together, iatrogenic comorbidity is what happens when medical treatment or examination causes two or more chronic diseases or conditions. In the case of our heart patient, let’s say that she was given antibiotics to fight against the iatrogenic effects of the infected stitches, but that she didn’t know she was allergic to the particular antibiotics. When she takes the drugs, she goes into anaphylaxis. Now, the heart issue, the infection, and the anaphylaxis are all comorbid conditions. A good physician needs to carefully understand what caused what issue in order to properly treat it, otherwise, he might misdiagnose and mistreat.

I am not a doctor, but I imagine it’s generally easier to trace iatrogenic comorbidity in physical illnesses. The heart surgery results in infected stitches which results in anaphylaxis. It’s an unpleasant outcome, but the progression is clear. Mental health, on the other hand, is inherently fuzzier. It is not uncommon for patients to present with comorbid conditions, like depression and anxiety. When medication is administered and more conditions show up, like suicidality, there’s no real way to know what caused what. Did the medication cause the patient to want to kill himself? Or would the urge have developed had the medication not been given? Was it the chicken? Or the egg?

There is a growing faction of psychiatrists and researchers who are calling for a drastic overhaul of the way we prescribe antidepressant and antianxiety drugs because of the risks of iatrogenic comorbidity. General practitioners, in particular, are being called out for defaulting to prescription antidepressants rather than recommending therapy. The argument, essentially, is that general practitioners are well…generalists. They are the traffic control of healthcare, designed to guide people down the appropriate specialist highway so oncologists don’t get bogged up with common colds. In theory, this means that GPs should refer someone suffering from depression to a psychologist for further evaluation. In practice, what often happens is that GPs prescribe an antidepressant (or multiple antidepressants) and send the patient on their way.

To put this practice in perspective, I lived in New York City for eight years and never once saw a psychiatrist for my Effexor XR and Wellbutrin XL. Furthermore, my GP only required that I see him once every 12 – 18 months, for a five-minute appointment. So over the course of nearly a decade, I got about thirty minutes of face time with the man who prescribed me daily psychiatric drugs. That’s fucking absurd.

So why is this happening? A general practitioner would never give a patient a script for chemotherapy, so why is it a widely accepted practice when it comes to depression and anxiety?

I would argue that a major factor is the fact that the iatrogenic comorbidity of chemotherapy is much more obvious and well-studied than it is with antidepressants. We know that chemo is a hell of a drug because it quickly makes most people vomit, turn grey, and lose all their hair. The iatrogenic effects of antidepressants though, do not develop in a common, linear way—if they develop at all. The same drug presented to four people with similar symptoms, background, and genetic makeup can produce four very different effects. One person may gain weight and develop insomnia. The second might sleep well but experience PSSD (post-SSRI-sexual-dysfunction.) The third may lose weight and have suicidal tendencies. The fourth may flourish for a few months, but show symptoms of bipolar disorder years later.

In all of these cases, when the patient goes back to their general practitioner because they’re not sleeping well or their weight has changed or they’re suddenly manic, what’s likely to happen? They get a sleeping pill or they’re put on a diet or they add a Lexapro back to their Celexa. Now they’ve got additional medication in the mix, which creates the potential for even more iatrogenic effects. And so on and so forth, until the patient is drugged up to their eyeballs and their system has gone haywire.

Does this happen every time? No. But it happens enough, and it’s avoidable if protocols are put in place to make it more difficult to prescribe antidepressants. I’m baffled by the fact that a course of some sort therapy is not considered a pre-requisite to prescribing antidepressants, especially given that research indicates that over the long term, therapy is just as, if not more, effective than antidepressants. Additionally, the positive effects are more likely to endure and there is little risk of iatrogenic comorbidity.

I was scrolling through Twitter when I came across a tweet by Michael P. Hengartner, PhD that read, “In my new open access paper, I critically discuss whether long-term antidepressant use has prophylactic effects, ie., whether long-term use effectively protects against depression relapses and why we must consider withdrawal reactions…”

Hengartner is one of my great new finds on Twitter. He’s a senior lecturer and research in evidence-based medicine with a focus on public health and social psychiatry. He is openly critical of the modern psychiatric system and its practices not because he’s anti-psychiatry, but because he’s pro-drug safety. His initial research on depression raised questions regarding treatment rates and long term outcomes, which combined with his research around selective reporting and flaws in the scientific process, led him to realize that antidepressant efficacy is likely overestimated and that the negative side effects have been underreported and minimized. Effectively, he’s stumbled across what many patients (including myself) have said all along.

But the difference between Hengartner and a huge faction of researchers and psychiatrists is that he isn’t’ turning his findings into an Us vs. Them debate. Instead, he’s acting like a fucking scientist and questioning our existing assumptions which is the whole point of science and advancing medicine in the first place. Questioning, analyzing, and building upon existing research is how we move forward. It is not anti-psychiatry or anti-antidepressants. It’s asking tough, critical questions to make sure that we are doing right by patients.

Though Hengartner is doing meaningful work that might actually change something, I still find myself scratching my head at some of his tweets. His audience, I assume, is mostly psychiatric professionals, so he has no reason to dumb down industry language for laypeople like me. A world like “prophylactic” makes me want to run to the nearest Buzzfeed listicle that provides about as much intellectual value as a bag of stale rice cakes. Still, I am trying to gain a deeper understanding of psychiatric and pharmacological research, so down the prophylactic rabbit hole we go.

pro·​phy·​lac·​tic | \ ˌprō-fə-ˈlak-tik also ˌprä- \

adjective

noun

I’m having flashbacks of someone referring to condoms as a prophylactic, so I guess I should have put two and two together…moving on!

In the case of pharmaceuticals, prophylactic drugs are medications or treatments designed and used to prevent a disease from occurring. Antibiotics taken to prevent infection before surgery are a good example, as well as drugs taken at the first sign of a migraine that keep debilitating symptoms at bay. Hengartner’s recent article examines the prophylactic use of antidepressants for depression, presumably in response to Saeed Farooq’s systematic analysis claiming that using antidepressants as a pre-emptive measure could help to prevent depression.

Hengartner’s interprets the existing research differently. He points out an often overlooked aspect of antidepressant discontinuation studies: antidepressant withdrawal. Withdrawal symptoms can appear erratically and don’t manifest universally across all patients. They are often confused with relapse, which according to Hengartner, compromises the validity of discontinuation studies.

He says, “It is difficult to quantify the extent to which events recorded as depression relapse in maintenance studies are related to withdrawal reactions, but different estimations suggest that it is presumably the majority.”

In short: We can’t know whether or not antidepressants could be considered prophylactic (or rather, the condom of mental health) because a relapse in depression and side effects of antidepressant withdrawal is often confused, misinterpreted, and misdiagnosed.

The more you know. Ding ding dong!

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Click here for Hengartner’s article, “How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding”