s0kr8s

...and now the plan is "never mind"?

https://rollcall.com/2026/01/14/hhs-cuts-2-billion-in-mental...

Damage still done, people.

I received word from several long-established recovery programs today that they expect to be out of business within days, weeks, or months as a result of these funds being pulled.

The damage being done here will be long lasting, not only due to the employees and clients impacted, but due to the impact on the broader business environment as well.

Until now, the government was viewed as a reliable business partner in these industries, and it definitely won't be viewed that way going forward: the chill on investment will be felt for many years to come.

In some ways, I'm starting to view this and related executive funding cuts as a sort of miniature debt default.

The argument in the paper is about clinical efficacy, but many of the comments here argue that even lower clinical efficacy at a greatly reduced cost might be beneficial.

As someone in the industry, I agree there are too many therapists and therapy businesses right now, and a lot of them are likely not delivering value for the money.

However, I know how insurance companies think, and if you want to see people get really upset: take a group of people who are already emotionally unbalanced, and then have their health insurance company start telling them they have to talk to an LLM before seeing a human being for therapy, kind of like having to talk to Tier 1 support at a call center before getting permission to speak with someone who actually knows how to fix your issue. Pretty soon you're seeing a spike in bomb threats.

Even if we pretend someone cracks AGI, most people -- at least outside of tech circles -- would still probably prefer to talk to humans about their personal problems and complain loudly if pressured otherwise.

Maybe if we reach some kind of BladeRunner future where that AGI gets injected into a passingly humanoid robot that all changes, but that's probably still quite a ways off...

Excellent point. Comment updated for accuracy.

The author's thesis is that the rise in home-schooling is driven by a desire to "opt out of being around average people," and he implies that he is not home-schooling his own children in part because he himself was home-schooled and believes that may have contributed to his own struggles with social stress.

However, given his self-description, it seems there is a decent chance he would have struggled with social stressors regardless of what education setting he was in, possibly even more so if he had been exposed to bullying or excessive social stressors in a more traditional public education setting.

Exposing oneself to just the right dose of poison in order to develop immunity is a delicate science.

When I was younger, I was also taught to believe that nurture always triumphs over nature, but as I got older and eventually had my own kids, I found out that nature was winning way more of those battles than I first realized.

Agreed. Titles and credentials do not mean what they used to, in education and a lot of other fields.

Sufficient erosion in the meaning and value of 3rd party teaching credentials then diminishes the relative value of outsourcing the process vs. doing it in-house: literally.

Digital surveillance is often marketed as a form of harm reduction, with a focus on some metric that is easy to measure.

What is more often ignored is the potential for harm creation imposed by the measurement process itself: after all, such externalities are subtle and hard to quantify, even if they may ultimately sum in total to a larger quantity, potentially yielding a net positive harm overall.

Some would likely argue that we should prioritize the known over the unknown, but I'd rather not sign up my kids to be your guinea pig, especially if you have already demonstrated yourself to be a rotten scientist.

The restructuring is not complete, though: a concession was granted to allow borderline personality disorder to remain for the time being due to industry concerns related to reimbursement, but the plan remains to ditch it eventually.

On an international level, there is a grand plan to ditch old Freudian categories like narcisissm, borderline, etc. in the upcoming ICD11.

There was never much evidence for such diagnostic categories, and I was told that if you look at notes from old proceedings of the DSM-III committee that their inclusion was an artifact of the political need to get buy-in from the then-powerful psychoanalytic groups at the time.

The ICD11 plan to have a single personality disorder bucket makes more sense to me. At its core, a personality disorder consists of a heavily reinforced and entrenched cluster of behavior that is significantly self-defeating and that actively resists common intervention strategies. From that perspective, you could either have endless personality disorder categories or a single category that summarizes the phenomenon.

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9881116/

I never suggested that there are good employers who don't pay their workers competitively.

I instead suggested that there are bad employers who pay above market rates as a way to compensate for problems with employee retention. Sure, they'll run out of money doing that eventually, but you'd be surprised how long a business can cover up their mistakes with such a strategy, especially with the right funding partners behind them.

If you have not had the misfortune of working for such a business, that's great, but I believe there are plenty of comments here on HN to support the notion that such businesses not only exist but are fairly common in any industry touched by Venture Capital or Private Equity, and I have seen many even suggest that their higher financial compensation ends up not being worth it in light of the added psychological and physiological toll.

Caution: you might get paid 50% more to work at a company that is 500% worse managed, and therefore is hemorrhaging employees so fast that the only way they can maintain staffing levels is to offer a hefty premium above normal market wages to get new suckers to take a chance on them.

If you're nihilistic and believe all employers are rotten, then jumping ship every 2 years might be a decent game strategy, but I tend to believe that good employers do exist and are just somewhat rare. So if you find a unicorn, I would recommend holding onto it.

Having worked in a position where it was part of the job description to periodically report parents to CPS, my experience was that it was actually quite challenging to get CPS to take up a case, even when there was lots of evidence suggesting abuse was taking place. In general, CPS seemed to work very hard to prevent false positives, and concerned itself far less with false negatives.

At the time, I remember finding that frustrating, but in retrospect I think it was the right approach. Why? Because invalid reports are always going to vastly outnumber valid ones, in part because it is easy to be judgmental about someone else's parenting for a variety of prejudicial reasons, so "innocent until proven guilty" should be the default stance of any agency tasked with investigating such reports.

That is why stories about shaken baby syndrome are so galling, because the faux-science sets up a "guilty until proven innocent" scenario, which is definitely the wrong approach.

I agree that it could certainly be both.

However, most professional boards are created with an explicit mandate to promote efficacy and competency, which makes a hypothesis like "benefits of (DEI) > benefits of (efficacy && competency)" rather troublesome for a professional board to rally around. Even if true, it seems out of scope.

The "more DEI = more efficiency && competency" hypothesis seem like it should be where a professional board should focus its efforts and messaging instead.

A lot of recent "ditch the exam" efforts across a wide variety of professions seem to be centered around post-2020 diversity, equity, and inclusion (DEI) initiatives (evidence: https://www.opb.org/article/2022/01/17/oregon-advances-alter...).

This is not always stated explicitly, but will turn up in board minutes if you have access to them. Many professional boards have added a DEI committee or incorporated language into their mission statement in recent years as well (Oregon bar statement: https://www.osbar.org/diversity/programs.html).

I'm never clear whether the hypothesis is "more DEI = more efficacy && competency," or whether the hypothesis is "benefits of (DEI) > benefits of (efficacy && competency)." The former hypothesis at least seems more testable, but I'm not sure whether anyone is trying very hard (meta-analysis: https://academic.oup.com/tbm/advance-article/doi/10.1093/tbm...).

In a service business, sweat equity is an awesome tool, not just for paying yourself, but also for paying your early employees.

One of the biggest obstacles you face when bootstrapping is that you need employees to grow your revenue, but you need revenue in order to pay your employees. It's a chicken-and-the-egg problem, which sweat equity can help to solve, at least to a limited degree: grant some sweat equity that vests over 5 to 10 years as a form of deferred compensation, then hope that your new employee / business partner boosts the value of your remaining equity in that time-frame by some multiple that is much larger than than the value of the equity you are giving up today. Then everybody wins.

I have found this approach very successful in my own business. It also increases the likelihood that when you want to retire some day that your own employees might be able and interested in buying you out, which means that you won't have to shop your medium sized businesses to private equity groups or search funds in 20 or 30 years when you want to get out of the game.

Part of building a middle class is not pulling up the ladder after you, which means you need to aim to enrich others -- specifically others who are not already wealthy -- alongside yourself.

I would argue that all businesses are lifestyle businesses. Dreaming of a lifestyle that involves 10 houses and a yacht? Become a VC, or join a company backed by one and hope it becomes a unicorn. Astronomical wealth and power are a LIFESTYLE, the same way that dreaming of a modest home, work that you love, and time to spend on meaningful relationships is a lifestyle.

Just try to avoid judging the lifestyles of others.

On the other hand, if someone has a child who is aggressively attacking anything and everything in site, no matter how they might have heard about PANDAS, I would argue that antibiotics might still be the lowest risk intervention and most prudent option to try if they fit the profile.

Yes, antibiotic resistance is a concern if you start handing out antibiotics like candy, but if PANDAS is truly as rare as everyone would have you believe, then prescribing antibiotics to every kid that comes in with a PANDAS profile is not going to move the needle much with regard to global antibiotic resistance.

Alternatives:

Prescribe them anti-psychotics or some other medication to sedate them?

Likely much higher side-effects and risk profiles than antibiotics.

Send them to a therapist in hopes that the therapist can behaviorally condition that aggression away?

Bad news: talk-therapy for aggressive behavior in children has terrible outcomes. Most likely scenario in the mental health system is that they end up in an intensive group treatment setting somewhere with other aggressive children, learn more sophisticated aggressive behaviors, and gradually get worse.

On the other hand, antibiotics have a fairly low risk profile. Some pediatricians do literally hand them out like candy when kids come in with an ear infection or sore throat. Maybe stop prescribing antibiotics for those kids, tell them to try some tea tree oil or some other natural remedy, and save the antibiotics for the kids who fit a PANDAS profile instead?

These cases aren't nearly as rare as the medical system would have you believe. Go to a residential psych hospital for kids, or a day treatment program for level 3 or 4 EBD children, and you'll see a bunch of them, many of whom have been languishing there for years.

These kids are are more of an ugly and inconvenient truth that the medical world would prefer to ignore, so these kids get chucked over the wall to the mental health system instead, which is better prepared to simply lock them up and quarantine them from the rest of society.

For the most part, I think doctors want to work mostly with helpless and grateful children, who willingly submit to tests and follow orders, not angry, aggressive children who claw and bite you no matter what you do or say. If you don't "behave" then medicine doesn't want you. Go see a shrink.

This is part of why I hate the term "behavioral health," because the emphasis is on restoring compliance. There was a movement in the 90's to rebrand "mental health" as "behavioral health" in order to make it seem more reputable and science-y, but I think that move back-fired. I think we delivered more compassionate care when the emphasis was on trying to some notion of a person's healthy subjective mental state, rather than trying to get them to behave.

I have been told that kids with PANS / PANDAS often get better spontaneously when they hit puberty as well, which some speculate is due to changes in the immune system that occur at that phase of development (the body stops producing T-cells), so there is hope for families that have young children that things can improve gradually with time on their own if you hang in there as well.

Recent research suggests that schizophrenia may also be immune-mediated or at least immune-system involved. See:

https://www.frontiersin.org/articles/10.3389/fpsyt.2022.8805...

I was at a psychiatric conference once where the presenter highlighted that the last condition that psychiatry actually "cured" was neurosyphilis, an infection-triggered version of schizophrenia, back in the 1940's.

According to the conventional PANDAS theory, due to biological mimickry antibodies against Step A bind to neurons and attack them, so there are antibody tests that focus on Strep A that are used as diagnostic tools in PANDAS, such as antistreptolysin O (ASO), anti-DNAse B (ADB), and streptococcal carbohydrate (anti-CHO).

However, there a lots of kids diagnosed with PANDAS who have high levels of those antibodies at some times but not at others, and there are kids with the exact same history and presentation who never show high levels of those antibodies at all. So it could be that there are actually a wide variety of situations in which antibodies that the body creates end up attacking neurons (see anti-NMDA encephalitis), and only some of them are even known about yet.

The central epistemological question with regard to PANS / PANDAS is not free will, but rather: how do you study or measure a phenomenon that violently fights back and is possibly even willing to die in order to prevent your attempts to measure or study it?

Try getting someone who is working overtime to try and harm you and destroy everything around them to have a blood draw done, or to lie down for 45 minutes for an MRI. It's not a cake-walk. Sure, you can sedate them, but the sedating medications skew the tests. In fact, in the context of an immune-mediated disease, any sort of measurement that induces stress may alter the immune system's state and skew your results, because the immune system and stress interact.

Trying to bring objectivity to the study of PANS / PANDAS is kind of like trying to bring objectivity to quantum-physics. Good luck getting a wildly chaotic, stochastic system to reveal its "truth" to you.

I suspect you could say the same with regard to free-will.

In fact, I sometimes think of consciousness and perhaps the brain itself as an extension of the immune system. There are interesting structural similarities between lymph nodes and the brain. That would then recast all psychological problems as a sort of auto-immune condition.

Long-time HN lurker here, and I think it's finally time to finally create a profile and post my first comment.

I'm the CEO of an outpatient mental health organization with 50+ employees (mostly just run the tech in the background these days), I have been a professional in the field for 18 years in a wide variety of settings, and two of my four children have intermittently had symptoms that match the description of PANDAS / PANS for the past four years. Happy, gentle kids prior to it, often complemented in public for their good manners, then sudden onset for both of them after a Step-A infection, starting with neurological signs (occular shudder), then Berserker-level constant violence afterwards.

What is most maddening for parents is how powerless the whole experience leaves you feeling. I know this field, had worked with kids with these symptoms in a professional setting where I was widely viewed as the most successful clinician they had ever seen, I leveraged every asset I had to try and get my kids help (called up a family favor with the owner of a Children's hospital) and STILL the response from the hospital was to say that there was nothing wrong with my children, everything they were seeing was simply "behavioral," report me to child protection, and accuse me of Munchausen's. Close family members concluded my wife and I were child abusers when we asked them for help, and ran for the hills as soon as they got a glimpse of what was actually going on.

At the end of the day, the reality of PANS / PANDAS is even possible is not something that anyone is prepared to handle. That an innocent child could suddenly be turned into a violent weapon of mass destruction at any moment in time at the drop of a hat is a notion from a zombie apocalypse movie, not reality. Zombie apocalypse movies are actually the best possible way to imagine what it is like to live with a child with PANS / PANDAS, including the intermittent groaning biting.

To give you a clinician's perspective, when I was a young clinician working with these kids, we didn't believe it either. Neuro-autoimmune disorders were not even on the map back then, and we were always told to assume that some sort of trauma was underlying the violent behavior, because what else could possibly drive someone to do those things? Parents would tell me, "but this came on suddenly, out of nowhere, they were a happy normal kid before," and we would just assume they were lying, clueless, or some combination of the two because we could never definitely rule out that some sort of awful trauma had happened. Sure, these kids never responded well to known trauma treatments, which definitely suggested something additional was amiss, but then again there has always been a subgroup of individuals with complex trauma who do not respond well to treatment, so...

Now that I am a parent, however, and these are my own kids, I can with a high degree of confidence rule out trauma as a diagnosis in a way that I never could back then. My kids are home-schooled so it's not like we missed some sort of bullying at school, my wife and I are both professional mental health therapists so we know every parenting and behavioral conditioning trick in the book, I'm moderately wealthy and can afford to provide them with anything they need, and yet still the violent behavior continues, in complete defiance of everything I was ever taught. I sincerely wish I could apologize somehow to all those families I worked with way back when...

One of the things that makes me the most angry is the fact that the mental health system I work in is complicit in maintaining the illusion that they can help these kids. Occasionally someone will observe one of my kids acting out and will say "you should take your kids to see a therapist," as if a little routine behavioral insight could get this all fixed up in a jiffy. And if you took such a child to a therapist, they would probably be happy to attempt useless interventions on these children for years (hopefully not at my business, but perhaps even there), but the truth is that the world of mental health has nothing to offer these children. Zero, other than perhaps some palliative care for the trauma of going through and endless waking nightmare and perhaps some slightly nicer containment and quarantining facilities than you might have in your own home. I've worked in the settings where these children tend to accumulate and for the most part they simply don't...get...better. Why? Maybe because the core problem is not "behavioral," but with therapy being "so hot right now," nobody can seem to tolerate the notion that it's not a panacea for everything.

For those of you who have posted comments about your own experiences with children with PANS / PANDAS, I commend your courage and determination to continue pursuing ways to help your kids in spite of the resistance and the absolutely terrible advice the world has likely given you on how to help them. Know that you're not alone. It seems like every time I tell my story to someone, they know someone who is going through the same thing. It's possible that the frequency and prevalence of this problem is actually increasing over time, but we don't have good numbers on what exactly is happening because most of the world is still busy denying that the problem exists. I am consequently glad to see this issue getting more mainstream traction, both in the Economist and on HackerNews.

Side-note: like with most things involving the brain, I think we are unfortunately still a long way from understanding how PANS / PANDAS actually works. We have some theories, but those theories tend to not hold up well in studies (which is why PANDAS was renamed PANS to broaden the range of possible etiologies) but likely the syndrome is complex and multidimensional, with a wide variety of pathways leading to a similar endpoint (including pathways that don't even involve the immune system), sort of like Autism. So don't assume that there is a simple answer either. There are lots of stories about things like antibiotics or IVIG helping, but they don't work for everyone and each case is likely to require a slightly different approach, so the more important thing is to never give up and commit yourself to a systematic process of trial and error until you find something that works for your kids and your family. If you can, get some medical-grade genetic testing done, teach yourself some rudimentary bioinformatics, then put your tech skills to good use by mining that CRAM file for gold. That process led to tremendously helpful insights and intervention strategies for my family that would never have been uncovered otherwise.