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Comment by Dylan16807 | Hacker News Reader

> Evolutionarily speaking, it seems likely that depression/anxiety are there for some purpose, and yet we treat them both like meaningless pain meant only to be banished using drugs. I believe both are signals that something in our environment is not working for us. They indicate emotional or physical needs unmet---needs for safety, autonomy, connection, etc.

> Often the individual suffering is fundamentally unaware of their own circumstances. I didn't realize how messed up my family relationships were growing up until much later. There are various reasons for this unawareness, but I believe the depression/anxiety are there to force our conscious self and the people around us to acknowledge that something is wrong.

If a situation is causing no problems outside of depression/anxiety, and you took away the depression/anxiety mechanism, there would be nothing wrong with it.

If there are other problems, then piling depression on top makes it harder to fix.

A lot of medical conditions cause chronic pain. The pain helpfully signals "something is wrong" once, and then keeps unhelpfully reminding over and over. You want to treat the pain itself in that situation. Sometimes the pain is the only thing you need to treat at all.

Being an indicator of other problems does not make chronic pain useful. Depression is similarly crippling and unhelpful.

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Oh, this is a fantastic and beautiful deconstruction of this argument, I LOVE this. The comparison to chronic pain is fantastic, because indeed, chronic pain is a side effect of many conditions, and if we were able to relieve the chronic pain somehow, we certainly would, but being currently unable, we seek means to treat the chronic pain.

I've often held that the most insidious part about clinical depression is its self-reinforcing nature. Deep clinical depression is throwing a person into a deep hole with thorns sticking out of the sides- every attempt to climb out of said hole results in swollen cuts and pain to the arms and body, rendering eventual escape more difficult with each struggle.

Eventually, it becomes like trying to climb out of said hole with no arms at all. It's one of my life goals to discover biochemical methods to help such people regain the use of their arms, or even essentially grow new ones.

I find articles like this one useful ONLY* insofar as they assist those who have gained use of their arms and cut away the brambles on the walls of the pit- for most others, it merely ends up encouraging more struggling, self-recriminations, and effectually a deepening of the hole. :(

I have this wacky idea that maybe, just maybe we should reconsider the point at which opiates would be appropriate for treating depression. I mean maybe make them a 2nd or 3rd line treatment... right now I'm pretty sure they'd only give you opiates once that whole "induce a controlled seizure" thing fails.

Sure, they're addictive, but the "opium cure" was used up until the 1950's[1] and it's not like society was overrun by addicts. (I admit it's possible that the circumstances have changed, but I'd need to hear an argument for that.) Plus the fact that both Buprenorphine and Heroin-Assisted Treatment have been successful... opiates can be given as controlled medicine, and I feel like many people could benefit from them.

Over 40,000 Americans die by their own hand every year.[2] I would much rather have 40,000 opioid-dependent living people if it helped them bear the weight.

[1] https://www.ncbi.nlm.nih.gov/pubmed/18956529

[2] http://afsp.org/about-suicide/suicide-statistics/

Rofl! These are interesting points, and honestly, cause for deep thought. If these premises are sound, one might argue that a large part of the rise of clinical depression as the problem is presently constituted coincided with the phasing out of the so-called 'opium cure.' XD

(I'm so not willing to commit to that position, but I mean, just looking at only those facts you've popped in right there, it sure looks like a possibility, no real harm in admitting the possibility of any given conclusion! :) )

I'd rather have opioid dependent folk than suicides, as well, mostly because I strongly trend towards any outcome where there continues to be choice and opportunity for betterment. Certainly worth exploring, at least in thought! :)

If you're interested in studying the closest thing to it, look at the rise in popularity of Kratom, a Southeast Asian plant containing opioid alkaloids. It's commonly used by opiate addicts as a replacement therapy, and also by others as self-medication for anxiety, depression, and pain.

I'm not recommending anyone try it... nobody's entirely sure if it's safe, or if it could function as a gateway drug to harder opiates. But it's worth considering the good it may be doing for some people.

About three years ago I tried kratom and a few hours into it I decided to start an exercise habit and I haven't stopped. I should try kratom again some day.

> Kratom.. self-medication for anxiety, depression, and pain. > But it's worth considering the good it may be doing for some people.

The only the good it's doing these people is turing them into opioid addicts with a new problem that has a good chance of eclipsing the original and a certainty of exacerbating it severely in the long-run.

each year 19,000 americans die from prescription opioid overdoses and another 10,000 die from heroin overdoses which often start with prescription opioid use.

In my experience (as an anaesthesiologist), people who use opioids as a response to non-pain problems are some of the most miserable people there are. It might work for a couple of weeks, but soon you're tolerant, addicted, intermittently withdrawing and your life becomes a wreck. "The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. " http://www.ncbi.nlm.nih.gov/pubmed/9018906

Using MDMA might be useful as it is non-addictive, but again habitual use leads to decreasing benefits and increasing problems.

Saying that prescription opioid use is a cause of heroin overdoses ignores the fact that the reason people move to heroin is because of the paranoia about addiction which causes their prescriptions to be cut off in the first place.

In the same vein (no pun intended) I've been looking for stats but not being able to find anything about what percentage of prescription opioid overdoses occur while the patient is being actively prescribed, versus those which occur when the patient is obtaining the drugs illegally once their prescription has been cut off because doctors are afraid they'll become addicted.

> afraid they'll become addicted.

Someone who isn't addicted to highly addictive substances doesn't engage in risky behavior, disregarding consequences and their well-being, by seeking out undosed, more potent and potentially adulterated highly addictive street drugs.

Maybe their doctor has a valid concern. Opioids are rarely an effective treatment for non-cancer and chronic pain if taken regularly for a variety of reasons.

Ideally, if a doctor is going to stop refilling a prescription of an opioid addicted patient, they should be referred to appropriate services. Detoxification, pain management and mental health specialists should be all be involved for the patient's well-being. The patient should never be cut off cold-turkey like that.

You sure about that? I'd imagine given enough pain for a long enough duration, I'd find a solution that either cures or kills me.

contrary to popular opinion these days, I think pain is undertreated and routinely so. quality of life should take priority over dependence concerns especially in the elderly.

But what is the root cause of pain? I used to be depressed and in a lot of pain. I could have got anti depressants and anti pain rXs. Turns out I was just fat and my body was mad at me. Switched to an active lifestyle and everything got better.

Does that mean it would work for everyone? No. But no doctor told me to go run. they either gave me medicine A or B or C, and changed doses to try and minimize side effects. It's terrible but I understand. I can't go to an overweight depressed friend and tell him he needs to fix his life not take drugs for his bad back.

Opioids are not a suitable treatment for long term pain, especially in the elderly.

People need rapid access to pain management clinics, with weight loss and strength building exercise, and access to meds (which in long term pain are often not opioids).

Giving those people opioids increases their risk of accidental death, and suicide. It gives them an addiction. But worse it does not treat their pain - they will still have the pain.

This is ignorant at best and naive at worst. God help anyone you treat, and if you aren't a medical professional its probably for the best. Your comment makes me physically ill.

You sound like a drug abuse apologist.

Which bit is wrong?

You seem to think pain control is opioids or nothing, and that's not true. There are a range of meds that should be used before opioids are tried. You also seem to think that pain control is only medication, and that's not true either. Exercise is a powerful intervention that can cure some long term pain (especially long term lower back pain). This strength building exercise is really important for older people too.

Opioids really don't work for long term pain. People develop a tolerance, which means they need to take more to get the same effect, but that means they end up taking dangerous quantities, and not getting pain relief.

Here's a Pubic Health England project to support prescribing of opioids: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

> 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

> 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation)

> 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is not increased benefit.

> 4. If a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.

Here's a BBC Radio programme about health. They visit a pain management clinic. People who visit that clinic usually have to detox from their opioid addiction before they can start the pain management work. This is because opioids really are not suitable for long term pain, and other meds / interventions should be used. http://www.bbc.co.uk/programmes/b04wv052

Here's a physician on HN talking about why opiates are not suitable for long term pain: https://news.ycombinator.com/item?id=10285321

> that the reason people move to heroin is because of the paranoia about addiction which causes their prescriptions to be cut off in the first place

Well it seems they are right, if people will move to an illegal substance right after they get cut from it

Pretty sure if coffee was outlawed tomorrow you'd see a lot of people moving to illegal substances. Doesn't mean people can't handle the substance, just means people who are cut off from substances they depend on will go out of their way to satisfy that dependency.

This is a tautology. You're not "right" to fear illegal drug use if your reaction to said fear (cutting off access to quality-controlled, measured doses) causes it.

There's a piece missing from this argument: opioids were inappropriately prescribed to start with in many cases.

Think of all those folks with back pain. Back pain is complex and difficult to treat, but huge components come from 1) the stupid chairs we sit in 2) at our stupid jobs that encourage hours of sitting 3) in our cities that discourage biking or walking to work, all in the context of 4) a food system that gives us crap to eat that makes us mildly addicted to sugar and salt and makes us unhealthy.

So the real cure for back pain for a lot of people is to go back 20 years in time, make a commitment to taking care of their physical selves, aligning their eating, transportation, work, and recreation with health. The second-best cure is physical therapy. Physical therapy right now! But that costs money and time and no one believes it works (it does!!!) so the pain med is seen as the proximate best answer.

Brings us back to the original original post, actually.

I appreciate your input as a medical professional.

Are you familiar with studies using NMDA receptor antagonists to reduce opiate tolerance?

For example, here's a study they did on mice: http://www.ncbi.nlm.nih.gov/pubmed/10763858

Also, don't you think your sample is biased as a doctor? As in: the people you're likely to encounter in your line of work are those that are in need of medical care?

I think mushrooms might be a better drug to give people than opiates. Send people to the redwood forest for a week to stay in a small cabin and eat mushrooms/smoke weed/eat good food and see how depressed they are afterwards!

There's some research happening recently arpund the use of ketamine as a short term measure to stop suicidal thinking or to get people out of deep treatment resistant depression.

So there's some possibility.

I don't think prescribing opiates to the right patient is a bad idea, or just make them legal--which will never happen.

That said, you, or anyone else are not going to get opiates from any doctor in the United States. The federal government is comming down hard on doctors who prescribe opiates.

The FDA just sent out prescribing recommendations to all doctors. It is stern. It's basically telling doctors just don't prescribe them--period! Or, only to cancer, and for palliative care.

It will go down like this; patent will go to that rediculious office visit to discuss their pain(a lot of that pain is real. Opoids make you feel better, so the pain is bearable. There are people who stay on their original doses.)

Doctor will just say--no.

Patient will detox, and might die, if old, or has underlying health problems. Just like the way Jerry Garcia died out in Woodacre, CA.

Or, patient will go to herion? If they live in the right area, and they are willing to break the law?

Whatever--getting any opiates will be very difficult. The average patient will be in pain. I really don't like the way the government is telling doctors how to prescribe.

(Bupenorpine shouldn't be thrown in the opiate mix. I have never seen anyone abuse it--period. I know it's opoid like, but so different. I don't even think it possible to OD on this drug.)

The way I've heard it put is that opiates are an extremely effective treatment for anxiety and depression, with the common and serious side effect of ruining your life. But I hear they're working on eliminating the side effects:

http://mentalhealthdaily.com/2014/12/20/ly-2456302-for-depre...

That does seem to be the conventional wisdom. But it's a bit contradictory, don't you think? I mean, crippling depression already ruins your life, and suicide... well, that's the ultimate life-ruiner.

Opioid replacement therapy seems to work, so I'm just not convinced that all opiates inevitably lead to doom... it feels more like FUD rather than anything backed by scientific evidence.

Agreed, that's an interesting take. Do you know if medical professionals differentiate chronic depression from acute depression? Is "clinical" depression related to one or both of those?

Depression is sometimes described a numbing experience. Everything loses color, loses that spark. Sometimes, everything hurts, nothing feels good. Making the same daily decisions is painful and slow, like walking through an ocean of glass.

Depression gives you the power to make really big decisions. Everything hurts about the same. Going to work is about as painful as staying home, meaning it's easier to quit a horrible job. It's easier to divorce an abusive partner. It's easier to pack up life and start over.

Having been through extreme depression multiple times, I can say with confidence that it makes those really big, really scary decisions a lot easier. You get thoughts like "it would all be over if I never saw that person again". "I would enjoy life if I got a divorce and moved back to my home town". "My job is abusive and it's slowly killing me, having no income is better than hating 70 hours of every waking week".

If you are depressed and having those types of thoughts, you might actually be right. Following through on those major, traumatic changes might actually be what you need to do. And depression makes it easy to do so. Normal life becomes so bad that change is welcome, because change feels like a way out.

> Having been through extreme depression multiple times,

Have you been diagnosed with depression by a mental health professional?

This is a really interesting perspective. Not sure if I agree with it 100%, but really something to consider. Thank you for sharing.

Absolutely. See also Winston Churchill, who cultivated his ailments into strengths: http://theconversation.com/winston-churchill-and-his-black-d...

This is exactly how I get out of depressive or anxious periods. Somehow the clarity of lying in bed being as painful as getting up hits home and whoop you're on your way out of the slump.

This does not work on all people though, I know of one person who's been resistant to medication, meditation, therapy.. none of it seems to truly change thought patterns. It just keeps coming back time after time.

I've seen one person really depressed, what I would call a major depression, not what most of us mean when we say we feel depressed. She was totally numb, like her brain was removed, all will gone. There was no reasoning, nothing going on. It was horrible to see, and very educational for me. It's good to see something like this, to understand it. I don't think she was ready to make any decision, but I may be wrong.

Just thinking out loud here: What about allergies?

In that model, what you need to fix is not to remove the trigger (e.g. the pollen may be safe) nor to inhibit the ability to respond (sometimes you need a big immune reaction) but instead to focus on whatever's gone awry with the fiddly logic in the middle that normally regulates frequency/severity/duration.

If that were the case, then the "depression reaction" might be a useful adaptation... but for some people it's occuring disproportionately.

>If a situation is causing no problems outside of depression/anxiety, and you took away the depression/anxiety mechanism, there would be nothing wrong with it.

The article's premise is that having one's core psychological needs go unmet is like having a broken bone.

If you take away the pain from a broken bone, you still have a broken bone. As you say, there is nothing wrong with taking the pain away. But the bone is still broken, and limits you in ways that a healthy bone would not.

Taking away the symptoms of an unwell psyche still leaves you disabled, even if it isn't as outwardly evident as a broken bone.

If you have a broken bone, it causes you serious problems outside of the pain. The pain is mildly important to alert you, and not very important after that.

Setting the bone is important, but if the pain makes it harder to fix the bone, drug it away asap.

And sometimes non-broken bones ache. No need to suffer it.

Yes but giving someone antidepressants for 30 years is like giving someone advil 30 years for a broken bone. Set the bone, then do advil for a week while it sets. But this isn't how drugs are used in the US. You get on them as a lifelong journey.

A large proportion of chronic pain is iatrogenic, or the product of maladaptive coping strategies. The canonical example is back pain; Standard medical advice was once a long period of bedrest, but this further weakened the supportive musculature of the back, creating a vicious cycle of pain and inactivity. The standard advice is now the exact opposite; Exercise is essential in spite of the pain, for both physical and psychological reasons.

There are often complex psychosocial factors involved, with access to disability benefits playing a substantial role in a large proportion of cases. Long-term use of opiates can cause hyperalgesia and rebound pain due to tolerance and withdrawal. Chronic pain is not simply a spontaneous biological phenomenon.

In the relational frame theory that underpins acceptance and commitment therapy, similar mechanisms are seen as integral to chronic anxiety and depression. Experiential avoidance is a common response to unpleasant emotions, but avoiding stimuli that trigger painful emotions tends to cause a paradoxical increase in the intensity and frequency of those painful emotions. Managed exposure to these stimuli is an essential component of a wide range of behavioural therapies.

> If a situation is causing no problems outside of depression/anxiety, and you took away the depression/anxiety mechanism, there would be nothing wrong with it.

My experience with SSRI's has been that taking away that mechanism is taking away creativity, emotional range, and introspective ability. Reality distortion is reality distortion. I reject procrustean medicine that fits humans to the mold of what is best for society, which is the primary environment in which anxiety/depression originate.

> My experience with SSRI's has been that taking away that mechanism is taking away creativity, emotional range, and introspective ability.

I'm not talking about SSRI's, I mean a theoretical way of removing only depression and the similar kinds of chronic anxiety. You can be very creative and introspective without being actively depressed.

> Reality distortion is reality distortion.

It's depression that distorts reality, even to the point of making you feel negative emotions that you know aren't true but can't stop.

> I reject procrustean medicine that fits humans to the mold of what is best for society, which is the primary environment in which anxiety/depression originate.

That's great. Me too. But that's really a different issue. You could fix that entirely, and you'd still have people hurt by depression.

What i'm suggesting is that its perhaps not even a coherent idea that one can remove depression without harming a person's mind in negative ways in the general case. There are some people who make fantastic recoveries with modern pharmaceutical treatments for mental disorders, but there are many who pay a steeper cost.

I'm well aware of how distorting depression is. I've been nearly bed-ridden for days at the worst of times. I am equally well aware of how distorting the pharmaceutical treatments for depression can be. It is like trying to correct a distorted mirror by putting a distorted lens in front of it for many people.

Some people have mental disorders that respond perfectly to purely pharmaceutical treatment. I don't know how many, but i doubt it's a majority or even a significant minority.

That can fall amongst their side-effects, but it doesn't have to be. If you are experiencing them you should absolutely discuss that with your doctor, and whether the side-effects are tolerable at the level they are at. They also don't distort reality, they raise the level of serotonin in your brain. Now on the opposite side we do not have a fundamental understanding of how any of that works. For instance, the serotonin levels in the brain of a healthy person might be lower than those of someone suffering from depression. We simply don't have the knowledge know why things are happening specifically.

Speaking from personal experience, which is all I can really do given that I am not a medical professional, they brought be back to a basic level of functionality. In direct regards to what you had mentioned they didn't take away creativity, emotional range, or introspective ability, quite the opposite in fact. Before I began treatment I was rapidly falling towards not ever leaving my room and hiding from people all the time. I am not saying they are for everyone. I just want to point out that we all need to be careful assigning our experiences to others on this.

Bad metaphors for chronic pain don't really help here.

There probably aren't any scenarios where, if you just removed the depression/anxiety "everything else" would be just fine.

What has happened is this: mainstream culture claims that these scenarios are fine when they are not, and so people seek to remove the depression and/or anxiety from them without even questioning whether the scenarios themselves are very healthy.

You're unable (unwilling) to accept that these circumstances are bad. You don't want to change them, you want reality to be something other than it is so that your culture can continue as it has without changing and growing. You would prefer that people numb themselves to it rather than address these defects.

The article's example is full of these.

* People pushed into college who do not want to be there * Parents of young children divorcing * Parents of young children remarrying * Shallow friendships * Hookups

These are not problems that will be easier to fix if he's doped up on prozac, they aren't problems you probably even want to acknowledge as such.

I appreciate this challenge to the article's viewpoint. My response would be that regardless of our unawareness of the causes, both emotional and physical pain are signals of things we need to pay attention to. Maybe chronic pain is the perfect analogue to depression/anxiety exactly because it seems to have unknown or untreatable causes. Maybe there is a need for painkillers in difficult chronic cases, but the vast majority of experiences of pain are functional and helpful.

Additionally, chronic pain conditions generally strike late in life whereas depression/anxiety come earlier. The emotional pain seems more likely to be adaptive whereas the seemingly meaningless physical pain later in life seems more like people's bodies breaking down.

Thanks for the critique.

> If a situation is causing no problems outside of depression/anxiety, and you took away the depression/anxiety mechanism, there would be nothing wrong with it.

The problem is that the connection between depression/anxiety and interpersonal relationships has been programmed into our systems by evolution. So the question remains if it is wise to alter our biochemistry to suppress mental illness.

>Depression is similarly crippling and unhelpful.

Though it must have some function or evolution would have got rid of it. My theory is keeping your head down may be helpful if you are screwing up socially. These days if the people who know you don't like you you can just move but in the hunter gatherer days that may have been fatal.

Evolution tends to keep things that increase survival chances, but it can also keep useless features. Also, when the environment changes, a previously useful feature may become useless. Evolution doesn't ensure that feature will disappear, unless it provides a major disadvantage.

Sometimes you can infer from evolution that a trait is useful. But only if the trait:

1. Is in a stable part of the genetic code, giving opportunity for bad traits to be weeded out.

2. Is not correlated with a different useful trait that overshadows its goodness/badness.

3. Shows up early enough to affect reproduction.

Human intelligence is quite recent, so prerequisite #1 is not met. We have no idea if prerequisite #2 is met, and prerequisite #3 is met.

So natural selection can't tell us if depression is/was useful. The kinks of human intelligence are not yet worked out.

#1 Dogs can get depressed so it doesn't need human intelligence. (https://en.wikipedia.org/wiki/Learned_helplessness)

#2 Depression has a major effect, I doubt it's overshadowed

#3 You get depressed teenagers

So I'd think 1,2 and 3 are met.

Re #1: There's absolutely no way to know if dogs experience "depression" in the same way humans do -- even assuming the outwardly symptoms are similar.

Re #2: Your doubt does not constitute evidence in any reasonable sense.

By that logic, why can I get sick at all? Why must depression only have social roots?

Therese are degrees of chronic pain. In its acute form painkillers are helpful. In its mild form there is always danger of suppressing a useful signal. The signal gives clues how small changes affect it allowing one eventually to find a remedy that works.

Similar with depression. Unless it is severe, it gives a hint to try to change something. Those changes can be really small, like getting enough sleep, or going to sea once in a while, or talking to an old buddy, or joining some volunteer activity. The key is to try and recognize the feedback that is impossible under antidepressants.

I really enjoy this analogy as well, thanks!

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