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The title, basically, which is why this issue is a day late.

Last week, I tore my ACL after taking a bad landing during practice for a gymnastics meet I was supposed to compete in this week. Everyone who hears about it wants to tilt their head and make some comment about getting older, which pisses me off because this injury was the result of gravity and physics, not age. The only time I’ve been feeling my age is when I look around at the world and simultaneously think, my god, I’ve been around long enough to see the bullshit double back on itself and come back again and also I’ve still got a lot more of this left to go.

In theory, anyway.

I know what a microtrabecular fracture with moderate marrow edema is now

I can’t say I’ve been thriving over the past eight months, and this injury and its long road to recovery isn’t exactly righting me on the road to flourishing. I’m not looking to beleaguer you for pity or words of encouragement. They’ll roll right off me and I don’t want to hear it. I only bring it up to convey the state of mind I’m in, which is probably why I’m purposely picking a public fight with Harvard psychiatrist Roy Perlis, who with all his Ivy League wisdom, truly thinks it’s a good idea to make antidepressants available over the counter.

On April 8, Stat News posted an opinion piece by Perlis titled, “The time has come for over-the-counter antidepressants,” wherein Perlis argues that antidepressants should be available without a prescription, just like ibuprofen or laxatives. (Don’t bother rewarding Stat with views by clicking the link. I’m going to break it down below.)

As sure as I am about the overall harm caused by casual, mass psychiatric drugging of the human psyche, I still leave the door open for counterarguments. I consider it part of my duty to stick to my guns only if they’re loaded, which means forcing myself to get out of the echo chamber and hear opposing opinions. So I read the piece, expecting a Harvard professor to at least make a well-substantiated argument, even if I didn’t agree with it.

Instead, it’s 900 words of one of the dumbest, most poorly cited pieces of “journalism” I have ever read in the mental health space. And that’s saying a lot, given the drivel that comes from pop-wellness websites.

Let’s take a look, paragraph by paragraph. Perlis begins:

Anyone can now walk into a pharmacy in the United States and buy oral contraceptives over the counter without a prescription, thanks to the FDA’s approval of norgestrel (Opill). This change reflects the drug’s safety and the public health imperative to ensure wider access to birth control. But another safe class of medicine that addresses a massive public health need remains unavailable except by prescription: the antidepressants known as selective serotonin reuptake inhibitors (SSRIs).

Let’s start with the immediate oddity. Why in the world is Perlis comparing an SSRI to hormonal birth control? What do these things have in common other than being a political football? If he’d instead compared an SSRI to over-the-counter supplements that act on the serotonin system, like St. Johns Wort or tryptophan, then maybe we have the basis for a relevant argument. Instead, he chooses birth control (in all likelihood to signal that he is not one of the Bad Men who took women’s rights away) and throws the word “safe” in front of both of them, as if there is any 100% safe medication. All interventions carry risk, and half the point of a doctor is to assess whether the risk of treatment outweighs the risk of the illness. Perlis sort of addresses this later in the article, but even by using the word “safe” in such a casual way, he is grossly generalizing while also patronizing readers.

These medications, which have been used in the U.S. for three decades, have repeatedly been shown to be safe and effective for treating major depression and anxiety disorders.

There’s that word again, right above the fold. Note how there is zero reference to support this. We are supposed to take his word because of the letters after his name. When someone else on Twitter pushed back against the safety claim with a study questioning antidepressant safety, Perlis chastised the user for “spreading misinformation” and then linked a meta-analysis he co-wrote along with a dozen others as evidence for antidepressant safety. I looked that paper over and noticed that at least half of the authors had declared conflict of interest statements. I responded to the tweet, asking Perlis why he would use a paper with so much declared conflict of interest to support a pro-pharma argument. Perlis blocked me along with the original user who called him out, and his response with the problematic paper is now deleted.

Perlis goes on to list the usual mental health woes including increasing rates of depression, long wait times for mental health services, and oddly, telehealth services whose quality of care is “difficult to measure.” He does not elaborate on how removing any clinical professional from the equation would improve measurement, but that’s par for the course for this dialogue, so I’m going to blow past it and focus on more egregious issues.

In reality, many OTC products treat symptoms or rely on consumers to diagnose themselves — think yeast infections, acid reflux, or respiratory infections. In the case of major depression or generalized anxiety, screening surveys have been developed for primary care that could help people determine their likely diagnosis with at least the degree of confidence of many OTC applications.

Ah yes, the screening survey. In no other area of medicine does a doctor make full diagnoses and prescribe solely based on a patient’s answers to a handful of leading questions. It’s working so well, too! People are thriving after being asked if, in the past two weeks, they’ve felt hopeless. Please circle “a little, sometimes, a lot of the time, or all the time.” And after you do that, we’ll give you a drug for the despair we can’t measure and convince you it’s your brain chemicals, stupid.

What about use or misuse? Depression is associated with increased risk for suicide, and medication overdose is among the most common methods of suicide. But walk through the aisles at your local pharmacy and pick any given medicine off the shelf: the odds are good it is more dangerous in overdose than an SSRI. Fatal overdoses are far more likely to involve drugs other than antidepressants.

Here’s where he really starts to lose me. Perlis uses overdose to defend his reasoning for the safety of SSRIs, claiming that it is more likely to overdose on other OTC drugs rather than SSRIs. This is bizarre because a Harvard psychiatrist should know that most people commit suicide by firearms or hanging and that even amongst poisonings or overdoses, people aren’t using their bottle of Zoloft to do it.

I’m unclear if Perlis was trying to make the argument that antidepressants are less fatally toxic at high levels than other OTC drugs, or if he’s trying to create a red herring that distracts people from the fact that suicidality and suicidal thoughts can be induced by antidepressants. I initially thought it was a poorly constructed argument for the former, but the next paragraph muddles it.

Among people age 25 and older, there is clear evidence that taking antidepressants does not increase the risk for suicide — in fact, the risk of suicidal thoughts or acts is reduced in this group, particularly among those 65 and older. For those younger than 25, the risk for suicidal behaviors or thoughts in clinical trials was modestly greater than that of placebo. So buying SSRIs over the counter could be restricted to people 25 and older, at least at first, just as some states restrict OTC pseudoephedrine (Sudafed) purchases to people age 18 or older.

Perlis is pulling data from a review by the FDA that examined the effects of black box warnings on antidepressants. Thanks to this study and others, it is well known that antidepressants increase suicidality significantly in younger populations. (A recent study used to approve the use of Lexapro for 7 to 12-year-olds documented a 6x increase in suicidality among kids who were put on the drug…and yet it was still approved by the FDA. See Dr. Roger McFillin’s take on that absurdity, here.)

It is incomprehensible to me that a psychiatrist in good standing would not only suggest a drug with a black box warning should be available over the counter, but that we can mitigate that risk by simply ID’ing whoever is buying it, as if the drug couldn’t then just be given to those under 25 as soon as the buyer walks out the door.

If Perlis ever grants me the interview I asked of him on Twitter**, my first question would be this: If some fifteen-year-old hangs themselves two weeks after starting OTC sertraline bought for them by their parents, who is responsible? The kid? The parents? Or the teller ID’ing folks at CVS?

Another objection to over-the-counter SSRIs is that not everyone believes in pills for depression. Some still question the biological basis of this disorder, despite the identification of more than 100 genes that increase depression risk and neuroimaging studies showing differences in the brains of people with depression.

Perlis goes on to draw an odd line between people not “believing” in the biological basis for depression and a study that looks at neuroimaging biomarkers as well as a Scottish study that concluded that people who “carried over 100 [changes to their DNA] were much more likely to develop the disorder in future.”

First off, the neuroimaging study he linked was connected to identifying the individuals who are most likely to benefit from targeted neurostimulation therapies, NOT antidepressants, which makes that reference null. Second, even if we did have the ability to easily test for these 100 or so mystery genes that cause depression (according to one study), does Perlis expect every person who walks into a CVS to have completed a full neuroimaging evaluation or DNA test before purchasing their sertraline with their toilet paper? If not, then how can you argue that this would be a broadly effective strategy?

To be sure, there are alternatives to pills. Certain talk therapies, like cognitive behavioral therapy, can be as effective as antidepressants, and some people prefer talking with a therapist to taking a medicine. But not everyone: weekly visits for eight to 12 sessions or more can entail substantial time and money. Here too, access to psychotherapists is a massive problem, particularly for individuals who seek to use insurance, or have none.

What this is saying is that Perlis is perfectly okay mass drugging lower-income folks under the guise of do-gooder benevolence. Please refer to the rise of Nazis for historical precedence on how that works out.

No treatment works for everyone, but around one in three people with depression get well with an initial antidepressant medication. Allowing over-the-counter access is not a panacea, but could open the door to a safe, effective, and inexpensive treatment for many who need it.

Perlis uses the STAR*D trial to report that one in three people who take antidepressants get well. Putting aside the recent calls to retract the STAR*D trial results due to significant violations of the originally submitted research protocol, Perlis’ own argument still suggests that the majority of people do not improve on antidepressants. Yet his strategy would expose 2 out of 3 people to iatrogenic risks and side effects of these “safe” drugs including but limited to suicidality, violent aggression, irreversible sexual dysfunction, mania, and damage to fetal development.

What’s needed to make this happen? An SSRI manufacturer with the courage to engage with the FDA and invest the necessary resources for a prescription-to-OTC switch, a well-trod path that has previously included medicines for allergies, acid reflux, and emergency contraception, among others. This process would primarily involve studies to prove that consumers can understand and follow the medication label, not new clinical trials, because more than three decades of evidence shows that SSRI antidepressants are safe and effective.

Perlis closes with a call to action from pharmaceutical companies, convenient because it absolves him of any downstream responsibility. He also continues to push the thread that depression is just as simple as contraception or acid reflux, even though those ailments occur due to a single, easy-to-explain mechanism. The same cannot be said of depression. Even in a world where biology was the sole explanation, it involves various processes (and apparently, over 100 genes) which means no single antidepressant would be suitable for all.

**Since Monday, this article is making its way around Twitter and I’m now not the only one picking a fight with him. However, in an odd twist, Perlis agreed to an interview with me. We’ll see if that materializes.

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Welcome to Science Corner by Happiness Is A Skill, where I take a few minutes to teach you about the relevant neuroscience of antidepressants and antidepressant withdrawal. No more half assed assumptions without evidentiary support, like the whole chemical imbalance theory of mental illness. The idea that “too little” serotonin causes depression? Or that “too little” dopamine causes ADHD? Obsolete, oversimplified, hogwash conveniently packaged by marketing departments of pharmaceutical companies in order to convince you to “talk to your doctor about Zoloft, because when you know more about what’s wrong, you can help make it right.”

That’s the actual tagline for Zoloft by the way, from 2001. Brilliant, isn’t it? Here’s a very simple explanation for your distress. It has nothing to do with your life or your choices or the bad things that happened to you, but instead has to do with some chemicals in your brain you can’t control. So take this pill and the sun will shine and flowers will bloom and scary thoughts will go away and we’ll all be content. Right? Right? 

If one could die of bullshit overload, I would long be gone.

Instead, let’s talk serotonin transporter (SERT) occupancy, something researchers have actually measured and analyzed in labs.

Let’s start with some background information. The serotonin transporter is a protein in the brain that helps regulate levels of serotonin. When someone takes an antidepressant, the drug binds to the SERT protein and blocks it from transporting serotonin out of the brain, disturbing the brain’s longstanding homeostasis by increasing the amount of serotonin available. When early test subjects reported an elevated mood after taking antidepressants in clinical trials, the assumption was that the increase in serotonin was responsible for this relief, therefore thus forming the basis of the serotonin theory of depression. If more serotonin = happier people, then less serotonin = sad people. And that’s how Prozac was born!

Too bad it was all a pipe dream.

Over time, the brain adapts to the presence of the drug and learns to produce less serotonin on its own. The body is always trying to get back to homeostasis, remember. The pharmaceutical industry spends billions of dollars trying to convince you that they can override hundreds of thousands of years of evolutionary physiology, but the bottom line is the body has to remain in equilibrium to stay alive. If you’re hot, you sweat to cool down. If you’re cold, you shiver to warm up. If either of those systems don’t work like they should, you die.

So let’s say you’ve been on 20mg Prozac (fluoxetine) for ten years and you decide it’s time to come off. Your doctor drops you to 10mg for a few weeks and you tolerate it. Maybe you’re a little emotional and antsy but you can handle it. Your doctor has heard about all this withdrawal stuff so he thinks he’s got it all figured out and tells you not to drop from 10mg to 0, but to instead cut the capsule in half and take 5mg for a week or two. You don’t feel great and wonder if it’s the depression coming back. But you figure you’ll drop to zero and give it a few weeks to know for sure. After all, 5mg is miniscule. Smaller than the smallest dose on the market! They give 5mg of Prozac to six year olds!

You drop to zero and all hell breaks loose—akathisia, huge emotional swings, paranoia, brain fog, gut issues. Back to the doctor you go, because clearly you’re sick and how stupid you were to think that you could operate without the Prozac. So you go back on 20mg. Hell, make it 40mg this time. Clearly, you need it. Your doctor suggests an antipsychotic as well because the paranoia suggests an emergence of Bipolar Disorder. Life, now, is all about managing symptoms.

Where did everyone go wrong? A fundamental misunderstanding of SERT occupancy.

Let’s look at the following graphs, courtesy of researcher Mark Horowitz:

The black curve is the measure of SERT occupancy as determined through brain-imaging techniques called PET scans that allow researchers to see the biological workings of the body. As you can see, at 25mg of fluoxetine, 80% of the serotonin transporters are occupied.

Figure (a) is a representative of the conventional line of thinking for linear tapering of antidepressants. Rather, the idea of lowering dosages by equal, measured steps—5mg, in the case of this graph. The problem is that if you lower the dose of Prozac from 20mg to 5mg—a 75% reduction—SERT occupancy only reduces by 20%. This means that not only are there fewer operating receptors, there is also less serotonin in the brain because the body long ago lowered its production. It is likely that withdrawal occurs at least in part because of this chemical imbalance created through linear tapering. And yes, it is ironic that this time, a true chemical imbalance is responsible.

Due to the hyperbolic nature of SERT occupancy, this dissonance is even more extreme at lower dosages, as seen in Figure (b). At 2.5mg of Prozac—20% of the lowest dose available on the market—SERT occupancy is 40%, just half of what it is at a robust dose of 25mg. This explains why it can be more difficult for people taper as they get closer and closer to zero.

Though SERT occupancy occurs with all antidepressants, the levels of SERT occupancy vary from drug to drug, as shown by this systematic analysis of 10 different psychiatric drugs, done by Anders Sorenson, et al.

The reason why you need to know about this is because it’s likely your prescriber is completely unaware. More understanding of SERT occupancy, as well as more robust research (especially when multiple drugs are involved), would lead to better de-prescribing practices that will likely lessen or eliminate severe withdrawal effects.

In the fictional example I gave above, our now “bipolar” patient needed a much slower taper that followed the hyperbolic curve and was adjusted only once she stabilized from the previous dose reduction. Had she tolerated a 10% reduction—from 10mg to 9mg to 8.1mg to 7.29mg and so on to 0—her brain likely would have had much more time to fire up dormant receptors and naturally ramp up serotonin production, leading to a more gentle, symptom-free re-introduction into a world without SSRIs.

Instead, when she was pulled off too quickly, her system went haywire because neurotransmitters are responsible for regulating the entire body. Instead of recognizing this as withdrawal, both she and her doctor assumed it was mental illness and plunked her back in the system with a shiny new diagnosis. This happens all the time. All. The. Time.

I hope you’ve enjoyed this Science Corner issue of Happiness Is A Skill. Please keep in mind that we are very much in the infancy of antidepressant withdrawal research, and that no single piece of information is the whole answer. But as they say on NBC, the more you know! Ding ding dong!

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Last weekend, I did something I rarely do: I went out. Like out out. I put on heels, wore makeup, and made chitchat with strangers at a fundraiser for a local museum. 

I was invited as a date for a friend whose husband went on a last minute business trip, leaving her as the lone stag in a group of eight couples. My butt did a great job of filling the seat, but a table of familiar faces brought not a sense of inclusion, but the sting of loneliness. 

The experience highlighted a nagging feeling I’ve had since MAY CAUSE SIDE EFFECTS was published in September. The book was, in many ways, my best friend. A constant, intimate presence, it persisted through the ebbs and flows of my life, the work often reflecting my reality. It gave me a sense of purpose, never wavered in its dedication, and showed up when I needed it. When it hit bookshelves, it’s like it moved away. It isn’t mine any more. It belongs to other people now, influencing their lives while I scramble to fill the void. 

Though the loss has gifted me oodles time, it also illuminates neglect. All of my relationships have suffered over the past five years, particularly my friendships. As a single person with no kids and a minuscule family unit—it’s just me and my mom, no siblings or notable extended family—I’ve always kept a mental running list of friends who would step up in a crisis, no questions asked. 

I don’t know if there’s anyone on that list anymore. 

Years ago I might have blamed this development on the failure of the parties involved, assuming we just didn’t try hard enough. Now, I understand that biology and social psychology is at play, and that itinerant life I’ve led isn’t conducive to creating and maintaining intimate friendships.

The number and quality of friendships is the single most important indicator of longevity and happiness and as we age, friendships become more important for health than family

But in 2021, 12 percent of American adults said they had no close friends, contributing to the loneliness crisis that began well before, but was exacerbated by, the pandemic. 

So how do we make friends as adults? More importantly, how do we create meaningful friendships that increase happiness? I dove into the research of evolutionary psychologist and friendship expert Robin Dunbar to find out.

You can only maintain so many relationships.

Robin Dunbar is best known for Dunbar’s Number, which he defines as the number of relationships people are able to cognitively able to manage and maintain at once. He puts this number at 150, which unsurprisingly, is just about the size of the average American wedding guest list. 

These 150 people are made up both friends and family and sorted into a sort of circular hierarchy. The closer the ring of people around you, the fewer the people in the ring. 

In the bullseye with you is an spouse or intimate partner, followed by three to five people who make up the first ring, usually family members and a close friend or two. The next ring expands and holds secondary characters. Grandma, perhaps. Friends you know very well but maybe not the one you call in a crisis. From there, we expand through the rings of fair weather friends, colleagues, extended family, old friends who live in different places, and so on through the target.

Friendships are created and maintained through consistency. 

Meaningful friendship is woven by shared experience and regular exposure. Therefore, the best way to make new friends is to engage in a consistent, social activity like a weekly meetup group. 

When we’re kids, this is automatic. We go to school or an after school activity, see the same people every day, and become friends. As adults, we lose opportunities for that natural interaction. Some people get it through work, but for someone like me who works alone and at home, I have to create it. It’s no surprise, then, that the people in my “close” and “best” friend circles over the years have come from going to the same CrossFit class, at the same time, five days a week for years. 

It’s also not surprising that over the past six years, when I was either traveling internationally or splitting my time between Canada and the US, my friendships suffered. I’d be in town for three weeks and leave for two months. People had babies in the time I was away. 

In my head, they still remained in the “close” or “best” category because I didn’t stay in one place long enough to forge a friendship strong enough to fill the space. But while I was away, my place in their hierarchy shifted, knocking me to outer circles. 

The characters in the hierarchy may change, but the quantity does not.

Where people stand in the hierarchy is constantly shifting. When you see less of someone because you see more of somebody else, it pushes people in and out of different circles. We see this happen all the time when people enter new relationships. In an interview with Dan Harris on the Ten Percent Happier Podcast, Dunbar said that falling in love can actually take the place of two close relationships, because the mental energy and attention devoted to the new person inevitably boots two people out of the ring. This explains why people disappear when they get into a relationship. It’s not because they don’t care or are blinded by love. It’s because we have limited capacity.

When the hierarchy changes, find acceptance

When life separates “close” and “best” friends, the instinct is to hold those people in their circles by keeping in touch through social media or phone calls. Though social media has a reputation for, you know, toppling democracy and obliterating societal mental health, it’s actually supports relationship intimacy. But with limited energy to devote to friendships, time spent on Facebook eats into opportunities for in-person connection. 

For relationships in the outer rings, this isn’t a big deal. But at the inner rings, intention is crucial. As Dunbar says, people might be “better off finding a new shoulder to cry on just round the corner, so when the world does fall apart, they can walk around the block, knock on their door and get a hug.”

Said another way by the lyricist Stephen Stills: “If you can’t be with the one you love, love the one you’re with.” 

Making new friends takes time, but it gets easier

The hardest part of making friends—especially in a new place—is the beginning. But once you engage in a community and show up consistently, proximity will eventually lead to connection. Once those connections are made, the circles naturally expand as people get introduced to one another, creating a flywheel affect that ultimately leads to the sort of event I found myself at last weekend. 

As I felt sorry for myself at the table, envious that these sixteen (!) adults had so much support for one another, I wondered what it was about me that made me feel so separate. 

The answer is that while I was off in Cambodia or Croatia for a month at a time, they were all moving back to Reno and starting their families. All of them have kids around the same age. They get together for play dates and PTA meetings. When the kids aren’t around, they share the common ground gained from so many years of similar experience, often within walking distance of one another. 

It’s a barrier I’m just not going to be able to crack. But that’s okay. There’s plenty of room for them in my “good friends” category, and now I won’t beat myself up wondering why I can’t bring them closer.

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One of the pitfalls of depression is that because it tends to come in waves, the habits we gather while we’re feeling okay often fall by the wayside when we’re feeling rough. And while I’m a huge advocate of forcing yourself to maintain those habits during times of darkness, I know that sometimes, it’s just not possible.

Luckily, we live in a time where technology is literally at our fingertips. There’s a lot of junk in that app store, but there are also a handful of stellar apps that can help hold your hand through the waves. Here are a few of my favorites.

Created by game designer Jane McGonigal, SuperBetter is an app that builds resilience. Born after a traumatic brain injury left McGonigal suicidal, SuperBetter brings the concepts of gaming into real life. For McGonigal, this meant accomplishing Power-Ups like putting on socks and establishing Allies with friends and family to help her achieve her Quest of returning to a normal life.

The game is fully customizable. If you are battling Depression as your Bad Guy, accomplishing little tasks like drinking a glass of water, walking the dog, or getting up off the chair and moving around all generate points that count toward your win. Over time, these accomplishments create change on a neural level, leading to an overall more positive state.

screen shot of superbetter application home screen

MoodMeter is an aesthetically pleasing, data-driven app designed to help you track and shift your day-to-day mood. This can be especially helpful for those suffering from depression because depression is the great manipulator. One dark day can feel like it erases ten days of progress, but if you have visual data that proves you are ultimately on the upswing, it can be easier to manage those dark days.

screen shot of mood meterapplication home screen

Drawing on 40+ years of research and clinical experience by psychiatrist Dr. David Spiegel, Reveri is a digital hypnosis app designed to create immediate relief from pain, stress, anxiety, sleep problems, and more.

Hypnosis is a tricky word often associated with quack therapists or stage shows. But in this context, it’s more of an imagination tool that helps kick the mind and body into a state of active rest. It is a state of highly focused attention, where distracting thoughts are decreased and the mind becomes more open to new ideas and perspectives.

Each exercise takes about 10 minutes and can be treated like a daily meditation. The one caveat is that because the app is new, it can be a little buggy. But given the team of people behind it, including neuroscientist Andrew Huberman and technologist Ariel Poler, it’s likely these issues will sort out over time.

screen shot of reveri application home screen

Need a little giggle? Order one of my Fuckit Buckets™.

gold the fuckit bucket charm

may cause side effects a memoir book picture and author brooke siem

After 15 years of depression and antidepressants, my mission is to help people find hope in the name of healing. My memoir on the subject, MAY CAUSE SIDE EFFECTS, publishes on September 6, 2022. Pre-order it on Barnes & Nobles, Amazon, or wherever books are sold. For the most up-to-date announcements, subscribe to my newsletter HAPPINESS IS A SKILL.

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Healing Depression through Factual Optimism

How do we find happiness when we are still depressed or in antidepressant withdrawal? We don’t. At least, we don’t aim for big changes. Instead, we go for getting it right 51% of the time. If we quantify happiness onto a scale that ranges from 0% happy to 100% happy, every decision we make alters our position on the scale. If we can get our life to a 51% Lifetime Happiness Average, our choices are validated by default.

The goal isn’t to reach 100%. On some days, 80% can seem like a stretch. Fifty-one percent, though, is almost always doable. And at 51%, we’re winning.

Little Changes Bring Big Results

Quantifying emotions helps us remain grounded and make decisions rooted in reality, as opposed to the reality created by the chatter in our heads.

If we have one “good” day a week, we are at 14% happiness. By making small changes to bring us to two good days, our happiness average rises to 28%. To hit 51%, we need to have average 3.6 “good” days per week.

To set ourselves up for more good days in a week, we apply the 51% theory to individual decisions.

pinteret graphic for blog post the fifty one percent, or, factual optimism

As long as each singular decision falls at 51% or higher, it puts us closer to our overall 51% Lifetime Happiness Average.

Decisions are based not on logic, but on how they make us feel. When we are faced with a situation, take a moment and simply ask, “Where does this decision fall on the scale? How do I feel when I think about it?

If the decision feels like it will bring 51% Happiness, go with it, even in the absence of logic or practicality. If we don’t know the answer, wait and gather more information. Patience is often the difference between 49% and 51%.

The beauty of the 51% Theory is that all decisions become easy decisions. Even difficult decisions are easy decisions. They may still carry immense consequence, but once the 51% threshold is crossed, nothing else matters. At 51%, we are already ahead. Make the decision and go.

It only takes a 1% shift to create momentum that can change your life. At 49%, we’re still struggling against the current. At 51%, we’re moving with the river.

When in doubt, make a graph!

The 51% Theory is not finite. If, over too many days, a particular decision that started off at 51% or higher begins to fall, something needs to change. If a situation falls to 40% or so, that’s the time to get curious. Is the drop tied to your emotions or external logistics? Did the situation change or did you change? Is the effort involved in getting it back to 51% worth your time?

When you don’t know the answer, focus on a situation’s effect on the overall average. Since the goal is to hit 51% over the course of your life, a situation that sits around 45% for a few weeks only incrementally lowers your overall average, whereas a situation that sits at 5% for a few days can be intense enough to bring the whole average down. The lower the situation on the Happiness Scale, the higher its priority. If I have you nail in your foot, don’t focus your energy on the splinter in your finger. Even if you have 10 splinters in your finger, it’s the single nail is causing the bigger issue. But over and over again, people focus on the splinters while ignoring the giant, rusted nail in between their metatarsals.

In years of implementing factual optimism, my life has changed dramatically. I wanted to see a visual representation, so I made a graph:

chart presenting happines average in 2016

This isn’t a true lifetime representation, of course. My father died in July 2001, when I was 15. Anything before that seems arbitrary since my childhood definition of “happiness” was whether or not my mom packed an Oreo in my lunchbox.

I was a typical teenager until my father passed, so I give 2001 a 35%. The “peak” in 2008 was thanks to a debauchery filled final semester of college that was quickly squashed with the reality and uncertainty of moving to Manhattan on my own. Overall, I estimated around 2.75 good days per week in 2008. I opened my bakery in 2011 but by 2013, I was lucky to get one good day per week. I implemented the 51% Theory in 2014, and by 2015, my day to day massively improved.

The Lifetime Happiness Average only tells a broad story. It’s more interesting to break down by year:

chart presenting lifetime happiness average

As you can see, 2016 was an emotional mess. In February, I made a decision based on the 51% Theory to leave my life in New York City travel around the world. Because one life altering decision apparently wasn’t enough, I also decided to get off the cocktail of anti-depressants and anti-anxiety pills that I’d been taking since my father passed away. Both of these decisions barely squeaked in at 51%, and I ended up creating a perfect storm of logistical and emotional hell that was extremely painful and even more expensive.

Even though the immediate consequences of these two 51% decisions created five of the worst months of my entire life, the after effects are proving to be worth as high as 86%. That’s six good days per week — the highest I’ve ever averaged.

In the depths of those five months, I reminded myself (and was reminded by others) that I made those decisions because of that 1%. Even though 49% and 51% feels similar in the moment, that 1% is the tipping point that creates momentum for positive change. At 49%, you’re still struggling against the current. At 51%, you’re moving with the river. And at the end of our life, however many days away, we can look back and say to ourselves, “It was all worth it. Fifty-one percent of the time, everything was beautiful.”


Need a little giggle? Order one of my Fuckit Buckets™.

three images of the fuckit bcket collection

After 15 years of depression and antidepressants, my mission is to help people find hope in the name of healing. My memoir on the subject, MAY CAUSE SIDE EFFECTS, publishes on September 6, 2022. Pre-order it on Barnes & Nobles, Amazon, or wherever books are sold. For the most up-to-date announcements, subscribe to my newsletter HAPPINESS IS A SKILL.

may cause side effects a memoir book picture and author brooke siem

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In a day and age when information travels at warp speed and lives can be irrevocably changed by one photo or a single tweet, there was something poetic about the speed of the 2020 federal election. All the bandwidth and technology in the world couldn’t move it along any faster than it was going to go. The outcome was too precarious and the stakes were too high for anyone to make an honest call. And so we waited, and waited, for more information to come in.

It is moments like this that pierced through my own fourth wall and grabbed me tight around the chin, forcing me to face the greater collective storyline and apply it to my own. While the United States idled at a crossroads that led us toward two very different futures, I also stood at a major junction. There were two choices, and I needed to choose one. Each somehow felt both beautiful and awful, and yet the rest of my life hinged on this choice.

It was too close to call.

But life imitates life. For all the faults of that election and the missteps of all the people involved, there was one thing huge lesson to learn from it: when a decision remains unclear, it is because all the information has not yet arrived.

We have conditioned ourselves to think that when we are presented with a choice, our only options are to pick one or the other and to do it fast. But there is an ever-present third choice that often holds the most power — the choice to wait.

Waiting is itchy. It prickles at you like a stiff wool sweater on a frozen winter night. But to rip it off too soon is to expose yourself to the elements without having first found shelter. If only you could wait until dawn when the sun rises to light the way. Life might look a little different then, the two paths now illuminated, obstacles in clearer view.

So we waited. And I waited, itchy and squeamish, for the information to come in. Because the outcome was too precarious. The stakes were too high.

It was too close to call.

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

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Back during my days of deep depression, one of my unconscious coping techniques was to put down the little things that brought other people joy. The phrase “that’s stupid” fell out of my mouth like a tick. Nothing and no one was safe. The ALS Ice Bucket Challenge? Stupid. Just donate money without the attention. Disneyland? Stupid. The most miserable place on earth. Hobbyist birding? Stupid. Who cares about random birds?

This reaction, of course, came from a most selfish place. I couldn’t find joy in anything, and it pissed me off that delight seemed so easy for others. I never stopped to think that maybe they took responsibility for their own happiness and worked for their joy. It never occurred to me that maybe they had pain too, but that they didn’t let suffering define them as a person.

The ability to experience a glimmer of joy is a litmus test for your psychological state. When I work with clients in antidepressant withdrawal, one of the first things I ask them to do is to start noticing little flickers of creativity, joy, or clarity that tend to come up as the drugs leave their system. These nanoglimmers of light may be barely perceptible at first, as simple as a deep inhale of freshly ground coffee or noticing how your eyes linger on the details of a flower. For people working through depression and getting off antidepressants, these nanoglimmers signal the mind’s innate ability to stop the mental loops and detach from the physical weight of depression—even just for a moment.

In my experience, as the nanoglimmers grew from fleeting seconds into longer chunks of time, the use of the phrase “that’s stupid” faded from my vocabulary and gave rise to curiosity and spontaneity. Birding might never be my lifelong passion, but what did it matter if other people enjoyed it? Who was I to put it down when it had no impact on my life?

To let others do their thing without making it about you is a hallmark of healing. They are on their path. You are on yours. It may take weeks or months or years of hard work to grow one nanoglimmer into a life filled with joy, but noting the existence of a single nanoglimmer proves that it is possible. What you can do one, you can do again. With time, one can always become two.

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

Johann Hari, author of New York Times bestseller Chasing the Scream and international bestseller 
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No fate is worse for those with anxiety than the act of doing nothing. But there is one tool you were born with that can help calm your mind and body when the weight of a situation becomes too much: your breath.

I am an XPT certified breathwork coach. Often, with my clients going through antidepressant withdrawal, I use my training to teach them how to breathe through the unpleasant side effects. But the techniques are relevant to anyone who suffers from anxiety, and yet little attention is paid to our breath.

Though breath is the single most important life-force on the planet, studies suggest that breathing dysfunction occurs in up to 83% of anxiety sufferers. Breathing dysfunction can negatively impact the body in a number of ways, including reduced blood flow to the brain, and sleep apnea, and higher instances of stress and anxiety.

Anxiety is the body’s way of alerting you to potential danger. It’s that “fight or flight” response that historically, motivated our ancestors to get scared and run away from a hungry tiger. But these days, most people aren’t being chased by a tiger (or its metaphorical equivalent.) Instead, anxiety is created in our minds.

Just because anxiety is created in the mind doesn’t mean it isn’t real. Physiologically, the body doesn’t know the difference between anxiety created because of a physical source and one created in our head. Think of a nightmare, for example. Even though we are safe in our beds without any physical threats, the situation created in our mind can shoot us up out of bed, drenched in sweat, and panting as if the dream was as real as the mattress underneath us.

The breath is like a remote control for the mind, and learning how to harness its power can mitigate the body’s stress response. Several studies have shown that deep breathing, specifically belly breathing that activates the vagus nerve, significantly reduces the stress response in the body. The vagus nerve runs from your brain all the way down to the belly, with branches that extend into your throat, heart, and lungs. When properly stimulated through deep breathing, the nerve regulates the nervous system’s response by turning down the intensity of stress and anxiety.

By breathing with intention, each of us has the power to operate our internal remote control, thereby gaining some authority over the anxiety. With an undetermined future ahead, there’s no better time to gather tools to manage our new uncertain world. You’re going to need every edge we can get, so let’s start with the one you were born with: your breath.

Morning breathwork, to set a calm foundation for the day:

Cadence Breath

Designed to keep you mindful of your breath while also helping your body to kick into a parasympathetic (calm) state, cadence breathing is an ideal breath pattern to ground yourself first thing in the morning.

To begin, sit in a comfortable upright position, either crossed-legged or in a chair. Take a moment to become aware of your breath. Actually look at it. Can you see your belly going out and in? Or maybe your chest moves up and down? Are your lips parted, allowing you to take in air through your mouth? Or is your jaw clamped down tight?

No matter how you typically breathe, commit to spending the next 10–15 minutes breathing only in and out through your nose and into your belly. Keep one hand on your stomach for a tactile reminder, and feel that hand rising and falling with each breath.

Begin with a cadence tempo of 2:2:4:2. That means you’ll inhale through your nose for an honest count of two (one one thousand, two one thousand…), hold your breath for a count of two, exhale through your nose for a count of four, and hold your breath at the bottom of the exhale for two. The crux of cadence breathing is to keep your exhale twice as long as your inhale, so if you’re comfortable at 2:2:4:2, increase the tempo to 3:3:6:3 or even 4:4:8:4. The slower and deeper your breath, the more the vagus nerve is stimulated to lower overall stress.

Breathing for when the anxiety is too much and you need to calm down, now.

4:7:8

If you find yourself on the verge of panic and you don’t have 15 minutes to step away and collect yourself, the 4:7:8 breathing pattern can knock anxiety down in just a handful of breaths.

Simply breathe in the nose for four seconds, hold your breath at the top of the inhale for seven seconds, and exhale audibly out your mouth for eight seconds. This is one breath cycle.

Repeat the breath cycle three more times.

If you find the 4:7:8 too challenging, simply speed up your counting while keeping the inhale:hold: exhale ratio the same.

Breathing for bedtime, because insomnia and anxiety are inextricably linked.

Long exhale + humming

Though humming has long been a staple of yogic breathing and meditation, science has only recently revealed the potential reasons why. Our paranasal sinuses are the main producers of nitric oxide, a gas that plays an important role in vasoregulation (opening and closing our blood vessels) as well as neurotransmission, immune defense, and respiration. When we hum, our nasal passages produce nitric oxide up to fifteen-fold in comparison with quiet exhalation, which leads to lowered blood pressure, heart rate, reduced anxiety, and a grounding feeling of calm that can lull us off to sleep.

Know that there’s a high chance of falling asleep during this exercise, so make sure you’re ready for bed before you begin.

Lying on your back with your head in a comfortable position, simply close your eyes and inhale through your nose, taking in a big breath into your belly. When you’ve taken in a full breath, begin humming and slowly exhale out all your air. Keep the hum deep and low and long, with the vibration coming from the back of your throat rather than your head. Repeat the humming breath for 10 minutes, or until you fall asleep.

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

Johann Hari, author of New York Times bestseller Chasing the Scream and international bestseller 
Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions

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“The calmer and quieter you breathe, the larger your blood vessels open, enabling better circulation and distribution of oxygen throughout the body, including the brain. Oxygenate the brain—breathe less.”

– Patrick McKeown, author of The Oxygen Advantage

In 2018, two years after I’d taken my last antidepressant, I found myself still struggling to remain steady in an unmedicated world. After fifteen years of relying on antidepressants and anti-anxiety drugs to do all the coping work for me, I didn’t have any sense of how to self-regulate my emotions or nervous system.

Around this same time, an acquaintance of mine, Taylor Somerville, became certified as an XPT Coach. Built on the researched-backed principles of managing stress response and wellbeing through breathwork, movement, and recovery, I went down the XPT rabbit hole and decided to get certified myself. Using Symmetry as a blueprint, my intention was to eventually use the XPT principles in my work with clients in antidepressant withdrawal.

Like most things in life, my plan strayed from reality. The majority of XPT’s methodology wasn’t a great fit for people in active withdrawal, but it was a perfect fit for where I was in my recovery. While Taylor went on to build Symmetry, a business dedicated to helping people regulate stress through breathwork and exposure therapy, I decided not to follow in his footsteps and instead, learn from him.

Two to three times per week, I pop into Taylor’s 45-minute, virtual breathwork sessions. Designed to combat dysfunctional breathing patterns and lower stress response, these sessions act as internal barometers, providing me with immediate feedback on my mental and emotional state.

You might be asking yourself, “How are breathing and stress connected? Doesn’t my body naturally know how to breathe?”

Take a look at this chart:

Carbon dioxide (CO2) is the metabolic stress messenger in the body. Suffocation, for example, occurs when oxygen levels go down and carbon dioxide levels rise to lethal levels. Although the body can survive without air for 4-6 minutes, most people will panic within the first 30 seconds due to increasing CO2 levels that create uncomfortable sensations throughout the body. These sensations release stress hormones into the body which increase heart rate, constrict blood vessels, and create a flustered state. Assuming we are not actually suffocating, all of this makes for a continual, negative feedback loop. Sustained over time, our CO2 tolerance goes down and our body remains in a constant stressed and anxious state.

The good news is that breathing is the only system in our body that acts on both a conscious and unconscious level. Because we have control over it, we have the power to change the level of oxygen and carbon dioxide in our blood. That’s where intentional breathwork comes in. By learning to manipulate our breathing, we can reverse dysfunctional breathing patterns and increase our tolerance to CO2, which leads to a lowered stress response.

I’m sharing all this with you today because Taylor is opening his virtual breathwork sessions up to a larger audience, and I figured someone out there in Happiness Is A Skill land needs to hear about it.

Come join me! Hit this link to sign up!

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

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A parable, borrowed from the religious but relevant for the atheists: A man is alone in his home when the storm comes. The local news channel tells him to evacuate, to move to higher ground, but instead, he shakes his head and says, “I will pray to my God and he is going to save me. I have faith” The rain beats down and the wind picks up. The streets start to flood and just as the water begins to rise over the man’s driveway, a knock comes at the door. A local policeman, with a rowboat, says it’s time to go, but the man shakes his head and says, “My God will save me. I have faith.” The wind wails and the water rushes in. It rises to the man’s ankles, knees, then hips. He climbs the stairs to his second floor, where it is dry. He waits there, for hours, and when a break in the storm comes he spots someone in a motorboat. “Come with me!” the floating figure yells, “The storm is only half over!” But the man shakes his head and says, “My God will save me. I have faith.” The eye of the storm gives way to more rain, more thunder. Water tickles the man’s toes, and he climbs the ladder to his attic. The wind rips the roof off his house, but when the man looks up, a rope is falling from a helicopter. “Grab on!” the pilot shouts, but the man shakes his head and says, “My God will save me, I have faith.” Reluctantly, the pilot recoils the rope and flies away. The man waits for his God to save him. But the house begins to crumble and soon the water is rising rising rising. It splashes over his legs and his torso and soon it is at his shoulders, his neck, his chin. The last thing the man notices is how the water shimmers on the tip of his nose. When the man reaches the heavens, he finds his God. “I had faith in you,” the man says, “I prayed to you. I believed in you. And you didn’t save me. You let me drown!” To this, the man’s God replies, “I sent you a warning, a rowboat, a motorboat, and a helicopter. What more could you ask for?”

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

Johann Hari, author of New York Times bestseller Chasing the Scream and international bestseller 
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To my favorite group of humans on the planet, this blog post is a little different because it exists just to tell you about my new favorite thing I’ve made: The Fuckit Bucket™.

Tee hee hee.

The Fuckit Bucket™ was born out of sheer delight. A friend of mine, embroiled in the world of C list celebrity and a nasty split from her baby daddy, was talking about how her life was so screwy that she was running out of fucks to give. I suggested that she put all the fucks in a bucket for rationing. A “Bucket ‘o Fucks” we called it. I even made a prototype:

I thought, everyone should have their own bucket. For two years, the Bucket ‘o Fucks noodled in my mind. I giggled every time I thought about it, and wanted to make a talisman of sorts to keep me giggling day to day. And then, sometime between 2016 and 2018, I heard the phrase, “Chuck it in the fuck it bucket and move on.” Fuck it bucket had a better ring to it, so I stored the phrase away. I would know when it was time.

In 2019, I caught a headline about how the Supreme Court deemed that swear words were, in fact, a form of free speech. The US Trademark and Patent Office would no longer be allowed to reject applications with swearing or immoral words or symbols. I searched “Fuck it bucket” on the USPTO website, and found that the phrase had not been trademarked. It was time to create.

As a former small business owner and small business lover, I did not want to produce the bucket overseas, even in exchange for a lower bottom line. After designing my little bucket, I found a smelter in upstate New York to cast the product. While he was pouring molten metal into my design, I went to work on trademarking. I figured that best case scenario, people would get a giggle out of the Fuckit Bucket™ like I do and snag them up on Etsy. Worst case, I wouldn’t sell a single bucket but I’d never have to buy anyone a Christmas or birthday present again.

Turns out, people love it. I launched the Fuckit Bucket™ just last week, as a response to the train wreck presidential debate. This year continues to pound down, and I decided it was time to bring a little levity back to the dog & pony show that is 2020. And given that we still have two more debates, an election, and the holidays coming up…well, everyone is going to need their own Fuckit Bucket™.

Buckets are available on a necklace, keychain, or as a stand-alone charm.

We’ll be back to our regularly scheduled programming soon, folks. After so many years of depression, I am basking in the fact that I can find so much joy in creating a silly little bucket. This is why we do the work. Because when we clear out all the emotional crap, we make room for creation and laughter to come in, which results in both art and delight!

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Happiness Is A Skill was created as an outlet for me to reach the kind of people who email me every day. Ever since my Washington Post Article, “I spent half my life on antidepressants. Today, I’m off the medication and feel all right” became the #1 read piece on WaPo National the day it was published, my inbox likes to fill up with people who are struggling to get off their antidepressants or benzodiazepines. I respond to every person who contacts me, and often that correspondence leads to a longer conversation.

About 12 weeks ago, after one of these conversations melted two hours away from my day, it occurred to me that I was spending a lot of time saying similar things to lots of different people. Why not take all that information and distill it down into a digest that could reach lots of people at once? And so Happiness Is A Skill was born. There are two overarching themes of these emails. First, people are desperate to find relief from the pain of withdrawal, all while trying to process the anger they have for prescribed drugs and doctors that were supposed to help them. Second, they are looking for someone, anyone, who understands. Psychiatric drug withdrawal is an excruciatingly long and lonely process that you simply cannot relate to unless you have experienced it. It’s rare to encounter another person going through withdrawal in the wild because people in severe withdrawal probably aren’t leaving their house. (And those who are experiencing mild or moderate withdrawal are likely so irritable that they aren’t exactly projecting warm fuzzies.)

Until recently, antidepressant withdrawal was swept under the rug by psychiatrists and doctors, largely due to a lack of substantial research surrounding long-term use and tapering. (Antidepressants and benzos are designed, studied, and tested for short term use, i.e., weeks. There is not a single study on the effects of long-term antidepressant use, and yet 1 in 4 people on antidepressants have been taking them for more than 10 years.)

But in 2019, a group of American and British psychiatrists came together and urged national withdrawal guidelines to be updated after they “discovered” what many patients already knew: it is a hell of a lot easier to start taking antidepressants than it is to get off of them. In a systematic review of existing research, the authors determined that “nearly half of those experiencing withdrawal (46%) report it as severe, and that reports of symptoms lasting several months are common in many recent studies.”

The authors go on to say that their evidence directly contradicts the position of the UK’s National Institute for Health and Care Excellence (NICE) guidelines, which state that “[withdrawal] symptoms are usually mild and self-limiting over about 1 week.” In short, this research shows that half of all antidepressant users will likely experience withdrawal of a substantially longer duration and severity than current guidelines recognize. Shockingly (to this American, anyway), the NICE guidelines were updated to reflect these findings, giving suffering withdrawal patients a smidgeon of validation. All this to say that the tides are changing. My article and others like it are finding space in mainstream media and a new cohort of psychiatrists and researchers are starting to take our claims seriously. But arguably the biggest contribution to bringing this issue to light is the new documentary, Medicating Normal. I had the pleasure of watching a screening a few days ago, and it both broke my heart and fed the fire within me.

A synopsis:

“Combining cinema verité and investigative journalism, Medicating Normal follows the journeys of a newly married couple, a female combat veteran, a waitress and a teenager whose doctors prescribed psychiatric drugs for stress, mild depression, sleeplessness, focus and trauma. Our subjects struggle with serious physical and mental side effects as well as neurological damage which resulted from taking the drugs as prescribed and also from attempting to withdraw. Says one psychiatrist, ’There’s not a chemical on the planet, to my knowledge, that can require years to tapernot Oxycontin, not crack cocaine, not heroin, and not alcohol. But psychiatric medications, any tapered patient will tell you, can take sometimes years if possible, at all.’ … [Medicating Normal] is the untold story of what happens when profit-driven medicine intersects with human beings in distress.”

Statistically, a good chunk of Happiness Is A Skill readers are taking some form of antidepressant or anti-anxiety/benzodiazepines like Xanex or Ativan. For those people, none of this is meant to scare you or bully you into getting off the drugs. You do you. However, if you ever do want to get off these drugs, I implore you to do your research and work with your doctor to create a slow, deliberate tapering plan. Doctors are not required to give patients informed consent when it comes to psychiatric drugs, nor are they well versed in safe withdrawal. It’s not their fault. The medical system simply doesn’t teach them how to take people off these medications. It is possible to wean off psychiatric drugs safely and with few side effects, but the techniques for doing so are being developed at a grassroots level by people who have experienced it, like me. For more information on safe withdrawal, check out SurvivingAntidepressants.orgMad In America, and the Inner Compass Initiative. You can also email me directly. Lastly, Medicating Normal is being screened virtually at several film festivals and hosted events. I would recommend it to anyone who is taking antidepressants or benzos, but I believe it should be required watching for all practicing psychiatrists and doctors. You can find tickets and upcoming screenings here.

Coming September 6, 2022

May Cause Side Effects

Brooke’s memoir is now available for preorder wherever books are sold.

This is a heart-rending and tender memoir that will start conversations we urgently need to have. It’s moving and important.

Johann Hari, author of New York Times bestseller Chasing the Scream and international bestseller 
Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions

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