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Comment by cassowary37 | Hacker News Reader

A colleague of mine calls suicide 'a permanent solution to a temporary problem' - not to diminish it, but to recognize that for most people the desire to die is a temporary state.

Whenever depression comes up on HN (as it does with surprising frequency), I'm both touched by people's willingness to share their own stories, and frustrated by otherwise very rational and logical people's speed to dismiss data. Initial treatment (meds or evidence-based therapies) work for about 1/3 of people; subsequent treatments work for another 1/3; and there are up to 1/3 where multiple treatment trials fail them. (This comes from STAR*D, plus Cipriani Lancet meta-analysis, plus vast CBT literature). But, there are a number of next-step treatments showing promise (rTMS, esketamine, variants of CBT, and so forth).

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> A colleague of mine calls suicide 'a permanent solution to a temporary problem' - not to diminish it, but to recognize that for most people the desire to die is a temporary state.

I've seen that quote floating around and never much liked it. For those afflicted with long-term treatment resistant depression, it's more like "a guaranteed solution to a permanent problem".

I've always disliked it too. It seems very presumptuous. The people repeating it typically don't know what the person in question is dealing with.

actually that statement is itself rather presumptuous. How would you know that those of us who repeat it don't know? I can state with authority that may of us do.

It's a truism in life that most people offering simplistic advice don't have long and deep personal experience of the malady they're advising on. None of us can guess about your experience personally, but that's the broad trend across large groups.

A lot of anti-suicide advice can seem like a sick joke, little more than empty virtue signaling. Want to really help? Offer a friendly ear and a sense that you really care about the person in question, and stand behind that over a period of time.

Being depressed is generally not a temporary problem. Many of us have suffered it for decades. It may wax and wane, but it's often not something that just goes away. In my opinion, it's something that many of us simply have to learn to live with, as with so many other chronic diseases.

> How would you know that those of us who repeat it don't know?

Because everybody is different and even if you have been through it yourself, your experience may be nothing like someone else's, and just because it was true for you, doesn't mean it is true for them. Yes, some people get past it, either on their own, with therapy or with medication. Some people are just numbed by it, other people learn to cope even if it never actually gets better. Other people still struggle every day. You cannot know what is going on in someone else's head or the struggles they face.

Its true that many people get better, certainly with treatment, but a large number of people do not (someone else here said that treatment does not work for approx. 1/3 of people).

STAR*D presents us with a "glass half full" problem. It's absolutely true that the majority of people will recover from depression with suitable treatment, but that leaves us with a minority who won't.

I'm not sure how to communicate those facts effectively to a wide audience. It is absolutely imperative that people with depression seek treatment and keep trying even if the first or second or fifth treatment fails, otherwise we're condemning people to unnecessary suffering; conversely, a lot of people with treatment-resistant depression are doubly stigmatised because of unreasonable expectations about the efficacy of treatment.

I do think it's useful for treatment-resistant patients to shift their focus away from recovery and towards symptomatic management - it's easy to get disheartened because you're not in remission, but a treatment that takes you from 10/10 depressed to 8/10 depressed is still useful. Eking out small reductions in symptoms and small improvements in functioning can be tedious and frustrating, but it's better than resigning yourself to interminable misery.

The term "treatment resistant depression" bothers me because, I think, a more accurate name would be "placebo resistant depression". Sorry to come off as frustrated; I'm like others in this thread with 10+ years of trying various therapies and antidepressants to end up feeling more, not less, hopeless.

David Burns does a good job explaining why antidepressants and psychotherapy don't typically work in his most recent podcast: https://feelinggood.com/2019/11/18/167-feeling-great-profess...

While David makes a good case against drugs and non-CBT therapy, I actually don't find his his fantastical anecdotes of the light-switch effectiveness of TEAM CBT therapy convincing either.

and HN refusal to pay attention to data when it relates to depression in 3..2..1...

https://www.ncbi.nlm.nih.gov/pubmed/29477251

for moderate to severe depression, the kind most posters are talking about, they're consistently better than placebo. It is true that placebo is often effective too. But most people I talk to would rather have that extra chance of getting better.

"We excluded trials that included 20% or more of participants with bipolar disorder, psychotic depression, or treatment-resistant depression"

This is an honest question - is it fair to exclude people for whom antidepressants don't work in an analysis of if antidepressants work?

If “placebo-resistant depression” and “treatment-resistant depression” were synonyms, we would expect that excluding treatment-resistant depression from your study would result in the studying showing precisely no difference between treatment and placebo. The fact that the meta-analysis shows any difference at all suggests that “treatment-resistant depression” might be a meaningful category.

I wouldn't dismiss a meta-analysis out of hand, but at the same time...isn't there a strong pressure to publish an effect above placebo? They rated 73% of the studies as having a moderate risk of bias, and certainty of the evidence ranged from moderate to very low.

I don't think that the real cure for depression can be bought or sold.

Bruce Alexander is talking about addiction here, but I think everything he is describing absolutely applies for depression: https://www.youtube.com/watch?v=7axaXQmdBVQ

I loathe this term. It’s like they’re shifting the blame for ineffective treatments onto the depression. If the treatments don’t work, the problem is with the treatments. Come up with something else!

> I do think it's useful for treatment-resistant patients to shift their focus away from recovery and towards symptomatic management

Would be nice but it seems risky for a patient to suggest that to the clinician; depending on the exact symptomatic management being sought and the competence of the clinician (who are not, unfortunately, exempt from Sturgeon's Law), it might get the patient falsely labeled as "drug seeking". That would be problematic, to say the least.

I suspect the amount of non-responsive patients is greatly downplayed by most therapists. Obviously they have a strong incentive to do so. From SSC:

> I work in a clinic with about ten therapists. Some are better than others, but all of them are competent. I send my patients to them. In a few hundred patients I’ve worked with, zero have had the sudden, extraordinary, long-lasting change that the therapy books promise. Many have benefited a little. A few would say that, over the course of years, their lives have been turned around. But sudden complete transformations? Not that much.

> When I try all the exciting new therapies on them, they just sort of nod, say that this sounds like an interesting perspective, and then go off and keep having symptoms. It’s very rude!

https://slatestarcodex.com/2019/11/20/book-review-all-therap...

He goes on to talk about how CBT success rates have been falling, seemingly due to the wearing away of its novelty-induced placebo. As a chronic depressive, my "temporary" 20-year-old problem (if you had cancer for 20 years, would you like people to call it "temporary"?), this is the most relatable and reasonable article I've ever read on the subject.

It's so hard to find the other side of the argument for therapy, I appreciate your links!

The advertising for CBT as an entry point for therapy is over valued. Therapy should really advertise more effectively as a social role rather than going deep into the task oriented stuff.

Is this data talking about a "cure" where people no longer would be labeled as having depression at all, or are we talking about clinically significant improvements/better than placebo results?

the studies (which admittedly are short-term) reflect remission - i.e., resolution of symptoms. This is a critical point: the goal is resolution of symptoms, not partial improvement.

The closest thing to a cure (for some people) can be cognitive-behavioral therapy, or long-term antidepressant treatment when indicated.

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