Most Depressed Adults in the U.S. Remain Untreated | Hacker News Reader

Most Depressed Adults in the U.S. Remain Untreated

scientificamerican.com

98 pointsaburan2892 comments

I'd wager that the vast majority of people that would test as being depressed are depressed because they are in a crappy life situation for one reason or another. I was depressed to the point where I barely left the apartment for 2 years, other than to go to work. You know what got me out of it? I bumped into an old friend who had just come back to the US from an extended backpacking trip. I ended up quitting my job and backpacking for 3 months. It totally changed my perspective on life, and I met my now-wife, who was also backpacking, and we currently have a kid and I have a much better job than I had before I left. Turns out I was depressed because I was bored and lonely, and all I really needed was a kick in the ass to get moving again.

There are obviously lots of people who seem to be depressed out of all proportion to what's going on in their life, and would benefit from antidepressants to get them going again, but I really don't think that it should be a first resort for all of them.

Poor life situations are depressing, but as a society we think drugs are the solution. There seems to be little encouragement to live more meaningful lives, which in turn will make us more happy and less 'depressed'.

Note: There are clinical cases of serious depression, but it seems most cases aren't that.

> but it seems most cases aren't that

I like to think this also, but is it actually true? Has anyone done that survey?

Seems like it would be hard to determine, but also, its against the interests of the drug companies that are selling the drugs. In addition, if it was publicly funded, how would we 'deal' with the conclusions?

I'm just pointing out that this is basically a comfortable way of looking at depression. I WANT to believe that most people on anti-depressants are just going through some shit rather than having something that needs medication for treatment. I WANT that, but I have no actual reason to believe it.

Sounds like you don't have any real evidence either.

Do you have any evidence to the contrary?

Well, we can use the income result as a proxy. 18% of lowest-income adults were depressed, 3.7% of highest-income adults. That doesn't preclude 'medical' depression, but it implies that it's at least mediated by circumstances, which is an interesting place to start.

Seems more probable that you have the cause and effect backwards. Being affected by depression prevents people from functioning well enough to work in a high income profession.

Seems even more probable that the controversy exists because it's a two-way feedback effect.

"More probable" feels like a claim that requires evidence, otherwise we're telling just-so stories.

I certainly think this is bidirectional, and it probably has some common-cause issues too (e.g. if your parents are too depressed to earn high incomes, you're getting an economics-genetics double whammy).

More to the point, though, your narrative is about 'medical' depression causing low incomes. Mine is about low incomes causing 'non-medical' depression, so realistically we're talking about different things. I'm sure they overlap, but I'm also confident that there's a difference between depression from "good life, but serotonin imbalance or immune response or whatever" and "lost my job, lost my house, lost a family member".

Most depression screens don't distinguish "depression because depression" from "depression because my life is shitty", and it's not at all clear that anti-depressants are more effective in one case than the other.

So my main observation here is that the high incidence at low income could be about untreated medical issues, but it could also be about a failure to differentiate medical from situational responses.

Without meaning to sound antagonistic, you're framing the question in the wrong way.

Research suggests depression is more like blood pressure, varying continuously in the population. There really isn't a clear line between depression-as-illness and other varieties of depression, only an increasing risk of problems as depression increases.

So in one sense, the research does support what you're asking, in that most people who experience depression aren't extremely depressed. But that's sort of tautologically true, in that if you have a normal distribution, most people won't be at the extreme by definition.

It's difficult to approach these things at a deeper level that I think you're getting at, which is "are most people who are depressed not seriously impaired by their depression" or something along those lines. That's harder to answer because it depends on defining "seriously impaired" which depends on sociological trends and so forth and so on.

This is the difficult thing about clinical depression, how do you know if it's truly a chemical imbalance or just the normal reaction to your situation? Sure, there are these screenings, but in my non-professional opinion they are pretty bad. Maybe it's an epidemic of false positives on depression screenings.

The chemical imbalance theory has little scientific support.

Google Dr Robert Sapolsky.

Google the area of chemical imbalance as an explanation for depression.

We still are in a pretty fuzzy area when it comes to depression and some other mental illness. Some things point to imbalance, others don't. It is really hard to screen for concrete sort of things when we don't have the science quite right yet, nor decent tests like we do with the thyroid. There might be some hope with things like MRI's being able to detect such things, but I highly doubt we are going to use that on a widescale basis nor that all that need screening can afford it. As such, the screenings really are a combination of what society thinks is normal, what the person relays about their mental activity, and whether or not it interfears with their life. And that is always going to be a bit objective.

I'm sure there are a few false positives: However, I'd also argue that there are probably more false negatives because so much of it depends on how the person reacts to the words. For example, you aren't suicidal, and you don't want to kill yourself, but you'd like to invisible or left alone most of the time. So you answer no to the suicidal thoughts thing. You just feel kinda numb and empty, so you answer no to the 'down mood' sorts of questions. You remember being happy about stuff, so that is out of the question. The question about losing interest in normal activities? Well, you've never really had hobbies or many friends, so that isn't even applicable.

Sometimes it is clearly the situation that is the trigger, but at that point there are two problems. The person's life events or lifestyle, plus a depression that keeps them from getting out. If you treat the depression bit, they might be able to see their way out or be motivated to take some action to improve their life. Some will still need help with this bit, and it is a shame there aren't support networks everywhere to help folks.

On a very important level: it doesn't matter. If you're depressed to the point of non-functional it doesn't matter if changing your situation would help because you're non-functional--you can't change your situation. Getting on antidepressants, or getting into counseling or therapy can (obviously no guarantees) get you out of the trough so you can make the changes you need.

The fundamental problem is how cripplingly little we understand about neurobiology. "Depression" is a label given for a common cluster of symptoms, not a single disease originating from a few well-understood causes. We aren't able to objectively test for or treat it the way we can X-ray a broken bone and set it or swab a throat for strep and prescribe antibiotics. There are no methods that are guaranteed to help the vast majority of sufferers and no clear understood root causes. All we can do is ask for the patient to report their subjective experiences and try to tick some boxes in the DSM, find a label that describes at least N/N+M of their symptoms, and then work through an associated checklist of wildly different methods of "treatment" that reduce symptoms in some, but not all (or even a majority, AFAIK) of patients.

I personally think that many (if not most) of the mental illnesses listed in the DSM will eventually be understood to be multiple completely unrelated root conditions that all manifest similar symptoms, each with different methods of treatment. Unfortunately research initiatives tend to be shackled to the DSM's set of superficial symptom groupings in order to get funding, so a deeper understanding of them is probably a long time coming.

You're not wrong, but it's worth noting that there are some really obvious things we could do which would cure a lot of people. Not, for example, requiring people to work 40 hour weeks when there isn't enough work to employ the entire populace 40 hours a week is one obvious measure, because it removes the need for people to sit at their desks doing literally nothing, and would result in more people being employed. Restructuring business so that people are rewarded for providing value instead of acting as gatekeepers of value would be another. Removing the near-constant bombardment of advertising from our emotional and social landscape would remove a lot of demands on people's attention and allow them to focus on activities they find meaningful.

The fact is, people are depressed because the powerful in our society benefit from treating the majority of our society like shit.

    > Not, for example, requiring people to work 40 hour weeks
    > when there isn't enough work...

Indeed. And the problem isn't actually the work load - but the lack of appreciation and meaning, the former being connected to the latter.

In this context: "The boss, not the workload, causes workplace depression" (http://sciencenordic.com/boss-not-workload-causes-workplace-...) - EDIT: focus is on "not the workload", I believe bosses are incidental and themselves a variable very dependent on existence meaning

But even the best bosses can only do so much to make jobs that require convincing people to buy stuff you know they don't need seem meaningful.

I bet after WWII when in the war countries the part of the population that remained at home had to work their asses off to produce until then unimaginable quantities of stuff nobody was depressed. The work had meaning. After it was over it helped that they had good job and income prospects - and reasonable long-term job security too. "Flexibility" is nice for those who can afford it.

I agree on the lack of appreciation and meaning, but the problem is more fundamental than good or bad bosses: the problem is that "bosses" rarely are a needed part of the process at all. A good boss can minimize the damage they do, but in the end, most bosses are just middlemen between producers of value and consumers of value, a position which allows them to siphon off value without providing any value themselves. Giving someone who provides no value decision making power over people who provide value is always going to result in the person who provides no value overvaluing themselves. It's no surprise that many people feel undervalued, because inherently bosses are overvalued.

That's why I said that even the best bosses can only do so much to make jobs that require convincing people to buy stuff you know they don't need seem meaningful. The reason I linked that article wasn't the bosses who I agree are not the essential ingredient, but the other part, which is why I also have that last paragraph: It does not seem to be the work (load) that is the main cause. I added an edit to the comment, thanks for pointing out the possible misunderstanding of where the focus lies.

>there are some really obvious things we could do which would cure a lot of people

I agree with a lot of your bigger complaints re: the labor market, but I don't think this is necessarily true.

Let's say that for a lot of people, their symptoms of depression are a direct response to external circumstances, and that these external circumstances are overwhelmingly job-related. Even if you assume that this is true (which AFAIK is a assumption, research hasn't definitively demonstrated this), changing their situation for them to have a meaningful career doesn't necessarily magically fix the depression developed as a result of their situation--it might, but it doesn't necessarily follow that it's an automatic solution. Some people diagnosed with depression see reduced or even eliminated symptoms with lifestyle changes, and some people don't respond to them at all. Even if the depressive symptoms were caused by external circumstances, they could be like a broken bone: caused by external trauma, but needing additional intervention to treat even after the violence has ended. Or a closer analogy, like PTSD: removing someone from the traumatic situation that gave them the disorder in the first place is necessary to treat their symptoms, but it's definitely not sufficient on its own. We don't understand enough about depression/mental illnesses in general to be able to offer any clear or universal cures, or suggest any clear and universal causes.

> I ended up quitting my job and backpacking for 3 months.

Imagine if you were unable to quit.

Yeah, believe me I know. I actually had saved up a enough money for the trip more or less by accident, just because my car was paid off and I was such a hermit for so long.

You're almost there. Maybe we should be questioning why so many people are depressed in the first place.

People all around the US (and in many parts of the globe) are seeing their economic prospects slowly disappear in front of their eyes as good jobs evaporate into thin air (and no, the increases in Walmart greeter, part time, minimum wage style employment or "gig economy" freelance paychecks don't count). Political turmoil, lack of true and diverse representation in the political system, an increase in racial tension, foreign instability. All of these things are weighing heavily on the mind of the average American, regardless of actuality.

You were able to solve your depression by almost entirely changing your life's focus and goals. Like you said, you totally changed your perspective... but you were only able to do so because I assume (since this is Hacker News) you have skills that translate to good job prospects in the information economy. This gave you the freedom to completely redefine your life.

Now imagine you have the same malaise, except you already had kids, a mortgage, debt with no real economic opportunity, don't have the financial strength to quit your current job much less take a vacation of any length, are being told by the TV that your way of life is being threatened by INSERT_BOGEYMAN_HERE, that a certain presidential candidate's election will guarantee catastrophic ruin, and to top it all off you can't (or don't think you can) afford to go to a doctor and get Zoloft because your new insurance plan under the ACA heavily dis-incentivizes taking action on medical issues.

I'm just scratching the surface here, these problems are huge and intertwining. However I feel this single manifestation is good proof of how seriously our society is being strained. People's social identities are being attacked and we're getting articles about how we need to push some of the most prescribed drugs in history to more people. On its face this is insanity. We need to start questioning the fundamental power structures that are creating these situations rather than continuously trying to bandage the symptoms or we will experience continued social decline regardless of technological achievements, improvements to quality of life, and advancements in other areas.

Yep and by definition you can't have a clinical diagnosis of depression if you have any life situation that would explain it better

MDD and the like are mental disorders, not moods

There is a line of thinking I see that I wanted to address. The idea that someone isn't depressed but instead are really unhappy with their lives, work or situation. It's been pointed out already that the difference is difficult to test.

The problem that thought doesn't address is how impossible it can be to change your life, work or situation. People in abusive relationships can feel trapped and even when a door is left open for them to leave they won't take the chance out of fear. A change that would break someone out of a depression who is in an impossible situation could just as easily end up in what could be called a psychotic break. Hurting themselves or someone else, thereby becoming free of the situation by being in jail.

I'd like to add that part of the solution to help those particular cases could be to promote a society of helpfulness. To know if they jump from that life, work or situation that they won't die or have to crawl back to their abusive trap.

There isn't an answer and I think that you should err on the side of caution by not being dismissive of depressed people. There could be something in their life making them unhappy but they probably can't find any healthy way out. Without anti-depressants many people self medicate with alcohol for instance which I would argue is a worse condition to exist in.

Anyway that is a lot of rambling to say there isn't a clear answer so please think twice before dismissing depression. Invisible diseases are incredibly difficult to live with for the very reason they aren't visible in a photo.

Depression is more about lack of motivation than it is about lack of happiness.

> The most common treatments for depression were antidepressants (87.0%), followed by psychotherapy (23.2%), anxiolytics (13.5%), antipsychotics (7.0%), and mood stabilizers (5.1%).

As a former therapist turned software engineer, herein lies the problem. 87% antidepressants? How are we defining "treatment?" Depression is a complex beast, and does it always require "treatment"?

I had a kid with my wife (together 10 years) about 15 months ago. Our little guy slept like absolute shit until a month ago, awaking multiple times per night, every.single.night. Nothing changed this; he finally grew out of it. We also moved, remodeled our home, and became a little isolated. I have suffered depression, including a period of hospitalization early on, dabbled with antidepressants, etc since adolescence. Never had psychosis, as I am lucky. I worked as a therapist for many years. I know this stuff. Yet due to psychosocial stressors, I fell into a period of depression for a couple months. The poor sleep mixed with isolation due to moving, and less exercise, probably. Gained 20 lbs. I know better, I know my triggers, I know warning signs, but it happened. Antidepressants would have masked the issues here. The side effects are subtle but serious over time. And they don't fix the problem for people with my kind of depression. Yet, my primary care doc would have prescribed antidepressants in a heartbeat. That is a serious problem with the medical system in the US.

What is "treatment"? Sleep, exercise and social experiences? Is there a way to measure that reliably and accurately? Probably not; that is why I take articles like this with a big grain of salt.

On a slightly related note; with all of your life changes, it's pretty easy to become Magnesium deficient. Please look into taking Magnesium Glycinate. It's made a world of difference in my depression. (just make sure you're taking at least 1,000mg a day, two capsules every 4-6 hours).[1][2][3][4]

[1] http://www.ncbi.nlm.nih.gov/pubmed/16542786

[2] http://www.ncbi.nlm.nih.gov/pubmed/19944540

[3] https://examine.com/supplements/magnesium/#summary3-7

[4] https://www.amazon.com/KAL-Magnesium-Glycinate-400-tablets/d...

I would like for this to be true. There are a bunch of red flags in the abstracts of those papers though. For example "Fortifying refined grain and drinking water with biologically available magnesium to pre-twentieth century levels is recommended." Seems to be overstating their case a bit. Anybody with more expertise care to weigh in?

Not a specialist in the field, but I note the journal where both those papers appear, Medical Hypotheses, explicitly disavows peer review, and was founded by a fellow [1] who seems to have spent his entire professional life under something of a shadow. I'd take those hypotheses with a grain of salt. But, if I were feeling myself unduly miserable (which happens sometimes), I might also take magnesium supplements for a while just to see what effect it might have on my state of mind.

[1] https://en.wikipedia.org/wiki/David_Horrobin

My experience is that cheap magnesium works better than the expensive stuff, at least when it comes to the mild sedative effects of magnesium.

While there's no harm in supplementing with small doses of Magnesium, it's also very unlikely to be the sole causative or curative factor in most people's depression. I'll address your studies individually:

[1] Refers to case studies (e.g. clinical anecdotes) of depression recovery following magnesium administration, but the number of cases is omitted. More importantly, there are no placebo controls to differentiate between spontaneous or placebo response and response to the magnesium supplementation. Finally, the article is in the context of severe magnesium deficiency, which is a strong selection bias that prevents the anecdotes from being extrapolated to the general population anyway. (Yes, I am aware that much of the US population does not meet FDA guidelines for magnesium intake, but that's not the same as being deficient in magnesium in the body).

[2] Is a good example of the importance of noting which journal the article was published in: In this case, it was published in Medical Hypotheses, which is dedicated to promoting diversity in debate by publishing hypothesis and fragmentary ideas that don't yet have enough real evidence to publish elsewhere. The first study it cites is from 1921, which was not placebo-controlled. The second study cited is from a journal dedicated to Magnesium research, but more importantly which pre-selected for patients with hypomagnesia. In other words, the study examined whether Imipramine (an anti-depressant) or magnesium supplementation were more effective in elderly type 2 diabetes patients who were known to have hypomagnesia.

[3] Refers to animal studies, but 3 of the 4 cited articles are about magnesium in migraine headaches. Perhaps the full-text articles have some embedded murine studies, but otherwise I don't see much evidence for magnesium treatment in humans here.

In short: It can't hurt to supplement, but it's unlikely to be curative. More importantly, recommending weak or unproven supplements to depressed patients can send them down a path of attempted self-medication with supplements that do not work, when proper medical treatment can work much more quickly and effectively.

I don't think I ever made the claim that Magnesium would cure. It has helped my symptoms. Hypermagnesemia appears to be very rare so it was a low risk effort for me. I've had positive results with it whereas other touted natural antidepressants have quickly petered out (St John's Wort, 5-HTP).

> What is "treatment"? Sleep, exercise and social experiences?

I would bet most doctors know that sleep, diet, and exercise are very important and they let their patients know that.

What do you do with a patient that's overweight and doesn't get enough sleep? Refuse to write a prescription that will likely help even if the patient doesn't have the basics under control?

I had high cholesterol (250 or something). With low HDL (the "good" cholesterol) and very high LDL. My doctor prescribed a statin, appropriate, and encouraged me to exercise and eat better.

I took the drugs, but didn't (for a couple years) do much about the exercise, and continued to overeat (to my credit, I ate healthy things, just too much of them). My cholesterol dropped, but I had to stay on the meds. Eventually I started exercising, cut my calorie intake, and lost 40 pounds. My doctor took me off the meds, cholesterol stayed low.

The point is this exchange with him: He was impressed that I'd lost the weight. Happy that I could go off the meds. But said, he prescribes the meds because almost none of his patients will bother to take his advice on diet and exercise. He has to help them somehow, but he's stuck in a situation where what they need is beyond his control to actually prescribe, but most of them will at least take a pill a day.

Depression (and anxiety and other conditions) are all, for the majority of sufferers, treatable with lifestyle changes. Buying a dayplanner and scheduling your work instead of running from fire to fire. Going out with people and having real, physical social interactions. Possibly moving to a healthier climate or changing jobs.

But most people won't do those things, so doctors are stuck prescribing a drug that will help their patients, but won't solve their problems.

Just to let you know that the data backs your doctor up. Every legitimate long term study of non surgical weight loss shows that it doesn't happen for the vast, vast majority of people.

1) ["In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within 1 year, and almost all is regained within 5 years. "](http://www.ncbi.nlm.nih.gov/pubmed/1580453)

2) Giant meta study of long term weight loss: ["Five years after completing structured weight-loss programs, the average individual maintained a weight loss of >3% of initial body weight."](http://ajcn.nutrition.org/content/74/5/579.full)

3) Less Scientific: [Weight Watcher's Failure - "about two out of a thousand Weight Watchers participants who reached goal weight stayed there for more than five years."](https://fatfu.wordpress.com/2008/01/24/weight-watchers/)

4) [The reason why it's impossible seems to be that although calories in < calories out works, the body of a fat person makes it extremely difficult psychologically to eat less.](http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-...) This is borne out by the above data.

5) [The only thing that does seem to work in the long term is gastric surgery.](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421028/)

I know. I'm not disagreeing with him. I was commenting on why doctors, at least my doctor who I generally consider good, go to drugs first. People will take them regularly, which gets them half-way to actually being healthy. But they won't do the things that will get them all the way to healthy.

> Depression (and anxiety and other conditions) are all, for the majority of sufferers, treatable with lifestyle changes.

That's quite a broad generalization. It's also naive and dangerous. All depression can't be treated with lifestyle changes, just as you can't cure type 1 diabetes or cancer through lifestyle changes. That statement is one of the biggest problems for people with mental illness: the stigma from the uninformed that someone who is depressed is weak, and that should "just get over it".

I didn't say all depression can be treated with lifestyle changes. Though my claim of this being true for the majority of sufferers is too bold. I should have stuck with my usual "many, if not most".

I wrote:

  Depression (and anxiety and other conditions) are all,
  for the majority of sufferers, treatable with lifestyle
  changes.

To restate this (including my too broad claim):

  The majority of cases of depression and anxiety are
  treatable with lifestyle changes.

And lifestyle changes are not "just get over it" prescriptions. They're major and incredibly difficult. Things like, move to an area with a better climate. Quit your job and take one with less stress. End some relationships. Pursue (challenging) physical activities to get in better shape and get more sun and fresh air. Those aren't easy to do or resolve, but stressful jobs, inactivity, lack of sunlight, poor relationships are the sorts of stressors that lead to many instances of anxiety and depression. Identifying the causes is incredibly important, and saying that people can't and that they can't effect change to improve themselves and their situation removes their self-agency, making them feel they are weak and incapable of controlling their own lives.

Drugs do work, and in many cases are necessary at least in the short-term. But they're poor solutions in the long-term for many, if not most, people who suffer from depression and anxiety.

Do you have any sources for your claims? "Majority of depression cases treatable with lifestyle changes" and "poor solutions in the long term for many".

I already said majority was too strong.

Regarding poor solution, here's a list of some of the side effects:

http://www.webmd.com/depression/features/antidepressants?pag...

These are some of the reasons people quit taking them, which can result in all sorts of tragic consequences if they don't stop taking them under guidance of a medical professional. Along with people who quit taking them because they "feel better". Cutting off these medications often results in a relapse (similar for anxiety medications). EDIT: And a lifelong dependence on a medication is a difficult thing for many people to deal with. When missing even one or two doses of these medications can result in a massive emotional shift, this is a fragile solution.

CBT (which is much more than just the "lifestyle" changes, my wording was, again, not the greatest) offers better handling of emotions and reduced risk (or mitigated effects) of relapse. Largely by developing coping skills and other mental/emotional tools in these lines.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/

What also can work well is a combination of both. But a serious risk with medication only is masking of the underlying problems. The individual can feel good, or at least not depressed or anxious, but the stressors and causes are still present. So when going off the medication (self-decided or medically guided) and re-encountering those stressors, they lack the skillset to handle it any better than they did the first time (without some amount of either self-directed or therapy-aided development of coping skills).

I think this gets at a bigger philosophical question about depression that few seem interested in engaging in.

Sometimes depression is a correct, reasonable, and even necessary reaction to un-live-with-able life circumstances. It's a way of your body generating warning signals that others might see and then offer you help, not unlike shooting up a flare if you're stuck on a life raft.

If the circumstances truly are un-live-with-able, then medication that simply makes you superficially feel like the circumstance is live-with-able, when really it's just continuing to be destructive to your life in every single same way apart from your now-masked-with-medication feelings, then medication can be counter-productive.

Many people with depression don't actually have un-live-with-able circumstances. Instead, they have live-with-able circumstances and either they have medical issues preventing them from doing the actions necessary to manage that living, or else they have what I'll call psychological issues preventing them from it, where 'psychological' here is meant to mean the subset of mental health issues that are not well-treated by medication, but may be treated with counseling or changes to other life habits.

The problem I've always faced when seeking counseling or mental health help is that every single mental health professional I've ever interacted with, every single time across many years and highly varied geographical situations, has always, always, always dismissed completely the possibility that a person can actually have un-live-with-able circumstances within which the depressive reaction makes reasonable sense. Instead, they begin from a point of view fundamentally rooted in the belief that that cannot ever happen to a human.

I mean, if they were pressed to think about like a child soldier forcibly addicted to cocaine or something, maybe they'd agree people really can have circumstances such that depression is the correct reaction. But in general, with first world people, they just assume it's impossible and have a pervasive Occam's Razor sort of filter, before ever meeting you or even talking to you the first time, that, nope, you're wrong about how you view your own problems, that there's no way you could be thoughtful enough to have done meaningful introspection before seeing them, and that your circumstances are never a justifiable reason for feeling depressed.

And from this attitude, the next step is almost always to suggest medication right away. And any time I've tried to say something like, "well, I'll consider medication, but I'm not just going to jump right into it. I want to speak more about my circumstances and explain why I feel like it's a real life Catch-22 that truly, utterly is depressing, rather than the depression being a part of me as I respond to it," then it's like talking to a brick wall. The counselor / therapist / psychiatrist doesn't want to hear about about. They already know you need drugs within one 1-hour visit, and now that you're saying you won't just rush right out and get them, that means further that you are a problem because you won't just go get the drugs you need.

And what's crazy is that the underlying rationalizations from the different mental health professionals have been all over the place. One person thinks it's because I have issues about my childhood and my father. Another thinks it's because I grew up in a relatively more religious community. Someone else thinks I have PTSD from an abusive relationship in my late 20s. Yet another thinks that it's related to overwork and job stress.

All of these are important issues and some mixture of all of them is affecting me. But every counselor I see has their own colored opinion about which magic answer it is, all those magic answers are different from each other, and yet, every one of them thinks that drugs, drugs, drugs is what will magically solve the problem.

It really gives me no faith in the mental health treatment infrastructure, and causes me to be even more guarded about when or if I will consider trying anti-depressants.

From some of these statistics, it makes me feel like anti-depressants are way over-prescribed, and that counselors are just extremely lazy. They don't want to hear the whiny, tearful narratives of their hurting patients' lives -- just like friends and family also don't want to hear it. And so shoveling out some drugs is an easy way to focus on something different than the thing they find unpleasant (i.e. actually listening).

There's depression the feeling, which may be caused by un-live-with-able circumstances and serve as a stimulus to make life changes.

Then there is depression the illness, which and may or may not be brought on by some circumstances, but which is debilitating.

If it's serious enough, I'm not sure if it matters whether it is spontaneous or caused - you need to be brought out of it before you can deal with the un-live-with-able circumstances. Staying in the depression doesn't help you to take action at all.

But the huge difference is that with truly un-live-with-able circumstance, the most important thing you need is help to alleviate the circumstance itself. Changing your response to it isn't helpful if it doesn't contribute to changing the underlying circumstance, and when the circumstances are things that you don't control which happen to you, especially when they are on-going and it's not so much about how you process them but actually stopping them, it's questionable what role medication really plays.

> Staying in the depression doesn't help you to take action at all.

It definitely can. Precisely when you lack the power to change your own extrinsic circumstances, and it is those circumstances causing the harm that leads to depression, then staying in the depression keeps sending out that distress signal for help. Taking you out of the depression without also addressing the circumstances makes it seem like you're managing it, when really you're still being harmed.

> As a former therapist turned software engineer, herein lies the problem. 87% antidepressants? How are we defining "treatment?" Depression is a complex beast, and does it always require "treatment"?

This is, admittedly, speculation on my part based on personal experience. Here goes. I'm sure you know this, but I'd like to throw it out there.

If I want to see a my regular GP and talk about mental health, I schedule a regular appointment and pay my co-pay for the visit and for any pharmaceuticals he prescribes.

If I want to see a mental health professional, I have to call my insurance company, describe my problem to someone who is not a mental health professional, have them pre-authorize visits (if they will), find an in-network therapist and complete treatment in the maximum 5 authorized visits per issue.

A system like this drives people to antidepressants.

There is one thing you forgot with the mental health professional: There is often a waiting time, especially if you get public assistance. I understand, in a way, as it is a specialty field, but then again, you might not have the bravery and motivation for all that long, yet not really qualify for even a semi-emergency visit.

My first spouse was bipolar/schizo affective: We were lucky enough to get a doctor fairly quickly, unfortunately it took a suicide attempt to figure things out. If he had to cancel an appointment, however, sometimes the waiting time was at least a month unless he was having a difficult time. Then it might be a couple weeks: More difficult than that probably meant hospital time. Luckily either the insurance I carried was flexible or the hospital was really good at negotiating with them so that wasn't an issue.

On the other hand, my nephew has needed a psychiatrist and therapist for some time. My sister had trouble even getting one in network, a harder time finding one to work with children, and generally had a long waiting time. Difficulty all around.

I scrolled down to the bottom of the page, and there's a little ad to subscribe to Scientific American 'Mind' magazine. One of the issues has 'How to Raise a Happy Child' across its front page, 'The essential guide to improving kid behaviour and resilience'.

That pretty much sums up the impression I get from American attitudes to parenting and early childhood. Behave, be resilient, and when the time comes, take your measly week of parental leave to teach your baby to behave and be resilient too.

Prevention is better than cure: the traumas of early childhood sow the seeds for a lifetime of anxiety and unhappiness. I don't really believe there is a long term solution to widespread mental health issues without concentrating on that fact, and enabling parents to provide the love, bonding and security their children require. But instead, in the US and here in the UK, we make parents' lives harder and harder (especially those in low paid jobs or out of work) and assume that an online course of CBT in a few decades will mop up any problems.

"the traumas of early childhood sow the seeds for a lifetime of anxiety and unhappiness." VERY well said!

The family unit has been anything but since the industrial age.

For ~99% of human history, families lived, learned, and worked closely together.

As of late, the opposite is now true. How can parents provide adequate love and bonding to their children when they both spend the majority of their time separated from each other with strangers at school/work?

What's more, not just the family as a small group, but also the larger groups of many families and generations remaining close and connected. Today with so many people moving around the country and even the world (me, for example, the latter as well as the former), those close networks just don't exist any more.

"Some groups, such as men and adults with less education, as well as ethnic and racial minorities, were especially unlikely to receive any treatment for their depressive symptoms"

I know that when I was making less money and had worse insurance, I never have even considered getting any kind of treatment for my depression. Me feeling bad and hating everything was something I felt I could deal with, and it took a low priority over pretty much everything else.

Unsurprising. It's expensive. Of course, you probably needed it more when you didn't make much.

Being unemployed is a huge risk factor for depression, but when unemployed how do you afford treatment?

Are more adults depressed, or are we just noticing it more? I can't tell if we're hitting the next phase of "just give the kids adderall" or if this is actually a problem with US society right now. The current popular jokes all revolve around hating your life and killing yourself, it's kinda strange.

>> "Are more adults depressed, or are we just noticing it more?"

Not sure if it's a good indicator but suicide rates seem to have jumped massively in the last 10-15 years.

I suspect that, at least in today's society, we have more to be depressed about.

Sometimes you're feeling bad about the world because the world's relationship with you is crummy, not because you're broken your self.

Some people I know have 'depression', really they are miserable about their work and lives. They tell the doctor their problems, the doctor jumps on giving them drugs.

Realistically, if they changed their jobs they'd probably be more happy, but drugs is the default solution.

While there are many factors, I'm convinced that our most popular social media platforms, Facebook in particular, cause depression.

It's anecdotal, but when I stay off FB I feel better about life. When I compulsively browse for hours, I feel terrible about myself, my friends, and the state of the world.

Intriguingly, Facebook has started doing sentiment analysis, putting them at risk of discovering with statistical rigor that their product causes depression. If so, their position right now is no different from the tobacco companies, in that they know that they're making their users sick.

I studied neuroscience in college, so have tried to stay up to date on what we know about the biology of things like anxiety and depression (surprisingly, we know very little for sure). The "chemical imbalance" hypothesis that I was taught in college and that is widely accepted is increasingly being challenged. For example, is it possible that depression is a symptom of a larger inflammatory problem vs. its own disease? Inflammation caused by stress or undiagnosed food or environmental allergies? (People with allergies have a higher risk of depression and suicide, especially in the spring. Allergy shots can help.)

In terms of non-pharmaceuticals, here's what seems to be effective: B Complex vitamins (make sure to get methylcobalamin form of b12 included not cyano), sleep, meditation, exercise, social support, omega 3, vitamin D, probiotics (refrigerated, not gummy), not taking NSAIDS, not taking proton pump inhibitors or antacids, low carb/very little sugar.

Please provide sources for the more interesting / outrageous claims. Especially meditation, probiotics, PPIs link to depression or the specific low sugar diet. Good quality controlled trials on more than two handfuls of people.

One of my best friends was able to drop his dependency on anti-depressants (which are a bitch) with 1 well prepared and well managed LSD experience (he had made 100% sure that the substance was indeed LSD and that the quality was the purest possible, spend tons of time researching every aspect). His experience was apparently so profound that he was able to stop all meds and since then never touched them again (remaining free from depression). Obviously, 1 dose of LSD costs virtually nothing, compared to anti-depressant prices (long-term usage), which may be one of the reasons it is not being pushed by the pharmaceutical lobbying powers that be. There's also a (real/licensed) doctor in Switzerland who has researched this substance/field very successfully.

Meditation is also very often mentioned for (not deeply/clinically) depressed people, as well as the Wim Hof Method.

EDIT: The case of the above mentioned person needs the following PSA: LSD is not for everyone: if you have anybody in your family who suffers from schizophrenia or psychosis, you may have this potential as well, which means LSD could trigger a crisis (but not cause the medical condition itself).

My friend took LSD and it made her anxiety worse. Another got an epileptic seizure while on LSD (never had one before or since the trip).

Not to say you shouldn't try it, I know several people who had positive experiences, but it's not 100% positive, as some people make it out to be.

(in before 'oh what they took wasn't actually LSD' from the 'LSD can do no harm' crowd)

just like heroin laced or replaced entirely by fentanyl, there are plenty of unsavory cats ordering NBoME or other compounds online and passing it off as LSD.

harm reduction circles always recommend testing the drugs yourself with a reagent kit, easily acquired online, because otherwise there is absolutely no way to know what was ingested.

not saying your friend didn't take LSD, nor am I naive enough to think LSD does no harm, just that if your friend didn't test the tab themselves, they have no idea what they took. unless they personally know the chemist, I suppose.

LSD is also a good anti-serotonin drug. It is sometimes helpful to take non-hallucinogenic doses of this agent.

Pro-serotonin drugs (SSRIs) are known to help people "not care" about circumstances in their life [1], which is why there is a lot of dissatisfaction with them.

[1] https://news.ycombinator.com/item?id=10974230

I don't buy it. Something else is going on. Look: Pretty much everybody I know is on antidepressants. Are we really facing a massive epidemic of sudden chemical imbalances? Everybody. I propose that our brain chemistry is unchanged, and unless you want to redefine normal in such a way as to exclude the entire current human population, the problem here is not medical.

The problem is medical, it's also societal. The solution is not chemical, but antidepressants are effective (for many people) in alleviating their symptoms.

Loneliness -> Depression for many people. Stress -> Depression for many people. The solution is to address those. What causes you stress, can you alleviate it, can you change your circumstances. What causes your loneliness. Can you move somewhere else, can you meet other people and develop a social life.

There is a (probable) chemical imbalance for most of these people, but the cause is not the chemical imbalance, it's the emotional/physical/mental stressors. They're what need to be addressed for long term recovery.

EDIT: I should amend this. Some cases of, particularly the severe cases, anxiety and depression are the result of an actual chemical imbalance where addressing concerns like the above won't help. In those circumstances, medication is certainly appropriate and probably necessary.

I saw this TedTalk[0] earlier that vouches this idea. The genes we got from our hunterer gatherer ancestors cannot sustain sedentary isolated life we live today.

[0] https://www.youtube.com/watch?v=drv3BP0Fdi8.

> sudden chemical imbalances?

Nobody credible believes the chemical imbalance stuff anymore. That doesn't make depression any less real - the fact that more people have a diagnosis might mean that a bunch of people who had unmet need are now getting the treatment they deserve.

It might well be chemical imbalance, but like most chemical systems in the body, it is probably a symptom.

Health care in the U.S. is not about health care. It's about wealth transfer.

1. People don't get effective treatment. 2. People start avoiding the system and its giant suck, even when it is to their detriment. It becomes difficult to discern whether this detriment is greater than that of "participating".

I would hold off on the hating on antidepressants.

Benzodiazepines, popular for anxiety, impair cognition, learning and memory and get in the way of the natural process of learning how to deal with life better and thus feel better.

Antidepressants do not. Antidepressants have an additive effect with psychotherapy, exercise, meditation, stress reduction, etc.

Also in cases of chronic pain where somebody is taking an NSAID or acetaminoprophen daily, many of those people would be better off taking an SNRI like Effexor.

>Nearly three-quarters of patients who were treated for depression were treated exclusively by general medical professionals, and those patients were less likely than patients treated by psychiatrists or other mental health professionals to have screened positive for depression or serious psychological distress.

I tend to see this kind of anecdote (data inference?) as a strong rebuttal to those who claim "Oh in the US it's not just like here, have a pill and you'll feel better!" when the people handing out the pills aren't specialists in the field where they're dealing out psychoactive substances. Would clamping down on the ability for 'general practitioners' to write scripts for stuff like this maybe help move the needle back into more rigorous treatment plans? Would it just cut off access to the drugs that otherwise help? Lots of implications to untangle, and I'm sure the pill industry wouldn't be really game to start making things more difficult...

One thing that I find worrying about this comment thread is how there is a general vibe of "antidepressants are evil". This widespread idea makes a lot of people who should be seeking treatment be reluctant to do so and as the article points out, right now under-treatment is a much bigger problem than over-treatment.

If you are feeling depressed you really should seek help from a psychiatrist. Having a face-to-face appointment with a psychiatrist will put you on a much better position to find out if you should be prescribed antidepressants or not (as well as other forms of therapy).

Is it possible that to be clinically depressed (on the milder end of the scale, perhaps) for years and be unaware of the fact?

Unfortunately, yes.

Yes. The worst part, for me, with depression is that my actions and beliefs were actually entirely rational during those periods. But the premises of my beliefs were false. Think of an axiomatic system for math, but add in 2+2=5. You can draw some interesting conclusions from such a system, but the basic premise has a critical flaw. Internally, you don't see it. You only see it from the outside.

Yes. Good clinicians should be trying to recognise subthreshold symptoms and providing advice.

https://www.nice.org.uk/guidance/qs8

> This quality standard covers the assessment and clinical management of persistent subthreshold depressive symptoms, or mild, moderate or severe depression in adults (including people with a chronic physical health problem).

Very much so. For example, Dysthymia (https://en.wikipedia.org/wiki/Dysthymia) often goes untreated. Some people develop this at a really young age, and simply don't know any differently. It seems that Atypical depression (https://en.wikipedia.org/wiki/Atypical_depression) can probably result in the same unawaredness, due to having positive feelings to positive situations.

It's important to say that the primary treatment for depression (87% of cases) is drugs, and it's now established that available drugs do not work. A now-famous series of meta-analyses (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/) that include unpublished drug studies show that, for the majority of clients, drug therapy shows no clinically significant benefit.

So when we read that the majority of depressed people aren't being treated, it's vital to remember that the majority of treated people aren't being treated either. The very real possibility exists that we have no idea how to either diagnose or treat depression.

Adults are screened for anything? When does this happen?

(Asked in a joke-like manor, but I am being serious, I can't recall EVER having been screened and don't feel like I'm an outlying case. How many haven't been forced to be tested?)

I'll just say something that might help the lads here. Get your testosterone levels checked. Sitting around, getting extra weight, my T levels were good... for a 90 year old. I've always had the "mind over matter" thing, looked down on manliness and testosterone, etc. Total nerd stereotype. I was so damn wrong.

So I read up on it and decided to take the plunge. The difference was immense. I feel so much more alive. Not even working out, I'm losing weight and getting stronger. It's the cheapest drug I've taken for the hugest effect. Everyone that knows me has commented, even when I was only 2 weeks in.

Please do not offer medical advice of this kind. While it is true that lack of testosterone can mimic some symptoms of depression (much less than low thyroid hormone for example, which should be checked first, it is not uncommon), the treatment has almost the same side effects as with any steroid hormone and the disorder is quite taste.

Part of the problem is that the cost of therapy, and all medical care, is skyrocketing in the US. We're working on lowering the cost with online therapy. We use a break-fix model where you only pay if we help fix your issues.

http://cheeseburgertherapy.com

Untreated meaning what? Un-medicated? I don't see that as a bad thing. The cause of depression is seldom one that medication alone can overcome.

Therapists... they're probably useful for some people.

For others, man what they wouldn't give to just have a few more friends, or something to do / some place to go where they felt welcome and needed. Medication doesn't help give people purpose or cure the underlying behavior that prevents them from building friendships.

This is a complicated thing, since there's no guaranteed cure for everyone, there's no reason to be concerned if people seek different ways to combat this deeply personal problem they face.

Some generic advice... eat healthy, get some exercise in the sun, keep your room clear from distractions (tv / laptops / cellphones) so you can sleep... just do the best you can. One foot in front of the other. Try and be social if you have the energy for it.

Untreated means that there aren't therapists nor medications for the person.

I agree that therapy isn't for everyone. However, some people are truly helped by therapists, especially if they are lacking life skills or coping mechanisms.

Those people that just want to have a few more friends or something to do where they are accepted? Well, medicine can help with that at times, depending on the situation. If they don't have friends because they work too much, and can't go places because of money or disability, the medication won't help them solve those things. The crappy thing is, however, is that some folks that are depressed long for these things, but they can't get out from under the fog enough to actually do anything about it. Medication often clears up the fog enough to be a productive person.

It is a complicated thing. It isn't a problem if people seek different ways, but that should include being ok with folks taking medication.

Your generic advice? Honestly, it just doesn't work for a lot of people with depression. Eating healthy and exercise is great if you have the motivation to do it: Not so sound advice if you can barely get the energy up to have clean clothing. One damning effect of depression is an absolute void of motivation to do anything What do you do if the distractions keeping you from sleeping are the thoughts in your head? Rumination and worry is a horrible thing They already are doing the best they can just by barely making it through a workday. Try and be social with a depressed and warped view of the world? That's a mighty difficult thing to strive for.

The whole point is that if it were possible to just do a few simple things and think or act your way to happiness, it'd not be such an issue. But not everyone can even get to that point.

Listen, without getting into too much detail, the root of solving depression is always the realization that you aren't powerless and you aren't worthless. You can do things, you can improve, you can add value to the lives of others, you can have the life you want... small steps get you there.

Letting yourself get into that rut, that dark space, it's very hard to get out of that. Medication, friends, therapy, success... if you're convinced you are worthless and that there's no point to anything... it won't matter what you have going since you won't see it.

Avoiding that, through some simple activities, is what I think is helpful. The focus of "curing" depression has to be preventing yourself from falling back into it.

And get a dog. They love you, they force you to get some exercise, and you always feel small accomplishments being able to take care of them.

They forgot to mention the corollary: most treated adults remain depressed.

Note: Most [of] Depressed Adults in the U.S. Remain Untreated.

Not how I initially read it: [The] Most Depressed Adults in the U.S. Remain Untreated.

I know, right ? I am not a native speaker and more often than not I can't figure out how to interpret such short titles, especially when it throws grammar out of the window in order to get something shorter. And yet they chose to take special care and went on capitalizing some words.

How very depressing.

Reply on news.ycombinator.com