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Comment by dimal | Hacker News Reader

Sorry, you are very very wrong about this. Have you ever talked to a _medical_ professional about depression or any mental health issue? They generally don't know what they're doing. Medical professionals only have one tool in their arsenal for depression: antidepressants. So a medical doctor will likely prescribe them, whether that's appropriate or not. Antidepressants are no joke. Sometimes they can help, but they can also cause really strange side effects, like increasing the possibility of suicide. And does the average doctor monitor all their patients regularly to make sure they're not having suicidal thoughts? Nope. And doctors generally won't know anything about the difficulty of getting _off_ the antidepressant if it didn't work.

Asking for advice on the internet is a very valid strategy, given the terrible state of mental health care in the US.

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Not OP, but I have. If you go to a family doctor in the US, they really aren’t qualified or trained in treating mental health.

My psychiatrist was fairly clear on what was what and which things needed to be treated with therapy and which medication could help with. (Medication helps symptoms, it does not cure.) Finding the right medication would take months or years and will not solve everything. There will be side effects that I needed to monitor and report. And so on.

When seeing any doctor, you are your own best advocate. It helps to come prepared, knowing your family history, and things you are struggling with.

Researching medications can help, but most people are not qualified to use them without supervision, myself included.

Note: This is assuming you need medication. It was fairly clear in my case medication was absolutely required to at least treat psychosis.

I prefer to refer friends to a therapist or psychologist, who do not prescribe medication.

Granted everyone's case is different, but my doctor went forward with medications only as part of a comprehensive plan to deal with my mental health which included seeing a therapist and committing to an exercise program (it sounded silly to be before, but exercise can be for some people can be nature's antidepressant). I'm on a 6 week to 3-month schedule of follow-up visits with my doctor to keep track of where I'm at mentally. Yes, there are absolutely doctors out there that will toss pills to people and send them on their way, but I don't think it's the majority. I also vet doctors the same way I would a mechanic or anyone else who is going to be doing important work for me. It can be hard, but there are doctors who care about doing the right thing out there.

> Sometimes they can help, but they can also cause really strange side effects, like increasing the possibility of suicide

This type of side-effect is thought to be mediated by 5HT2C activation when initially starting SSRIs, however, over the period of about two weeks, 5HT2C receptors downregulate and reach an equilibrium that can cause the effect to diminish or go away entirely. As an aside, there's research that suggests that abnormal amounts of upregulated 5HT2C receptors are present in suicide victims.

One of the reasons Prozac is recommended as a first line of treatment, besides the fact that it has a long half-life, is because of its 5HT2C antagonism that can block 5HT2C from extracellular serotonin activation from SSRI effects.

There are also plenty of antidepressants that don't typically cause that particular problem, especially if they aren't typical SSRIs or serotonin agonists.

> Sometimes they can help, but they can also cause really strange side effects, like increasing the possibility of suicide

FWIW, my understanding is this has little to do with the drugs and mostly to do with the recovery process.

In a deep depression, you might have suicidal thoughts, but lack the will to take action on those thoughts (because depression takes away your motivation). As you a person comes out of depression, they tend to recover their motivation before their suicidal thoughts dissipate. This creates a situation where a person with suicidal thoughts now has motivation - which means they have the potential motivation to take action on their suicidal thoughts.

The important nuance of this is anti-depressants don't necessarily make your suicidal thoughts _more_ suicidal. In fact, it's likely, anti-depressants are making your suicidal thoughts _less_ severe. However, they do increase your motivation before they can fully eliminate suicidal thoughts.

I'm not saying you should take an anti-dpressant willy-nilly. It's just BS to be fear mongering like this without considering why this situation happens.

In the beginning of SSRI consumption, it causes initial 5HT2C upregulation and activation, which can directly cause feelings of anxiety, dread, hopelessness, and restlessness/akathisia[1]. Over time, however, the body down regulates 5HT2C in response to its activation, and those symptoms tend to dissipate.

In a way, yes, there can be feelings induced that can provide the motivation and energy to go through with suicidal thoughts, but those unpleasant emotions aren't exactly triggered by an inherent will to die. Those who experience akathisia sometimes feel like the only way to rid themselves of the feeling is to end their lives.

I point this out because it might seem, or feel to those experiencing it themselves, that those suicidal thoughts are organic and what the person really wants, but they tend to be exacerbated directly by medication and can get better with time. I also point it out because there are ways to sidestep 5HT2C activation with different medications or combinations, it doesn't necessarily have to be inevitable.

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

I didnt find any info on 5HT2C in the linked source above, not saying what you've said isn't true, just that I was interested and didn't find much info.

Here's Wikipedia's summary, there are sources cited in the article[1]:

> Research indicates that some suicide victims have an abnormally high number of 5-HT2C receptors in the prefrontal cortex.[13] Agomelatine, which is a 5-HT2C and 5-HT2B antagonist as well as a MT1 and MT2 agonist, is an effective antidepressant.[14][15] It has been called a norepinephrine-dopamine disinhibitor because antagonism of 5-HT2C receptors by agomelatine results in an increase of dopamine and norepinephrine activity in the frontal cortex. Conversely, many SSRIs (but not fluoxetine, which is a 5-HT2C antagonist[16]) indirectly stimulate 5-HT2C activity by increasing levels of serotonin in the synapse although the delayed mood elevation that is usually typical of SSRIs is usually paralleled by the downregulation of the 5-HT2C receptors.[17] Many atypical antipsychotics block 5-HT2C receptors, but their clinical use is limited by multiple undesirable actions on various neurotransmitters and receptors. Fluoxetine acts as a direct 5-HT2C antagonist in addition to inhibiting serotonin reuptake, however, the clinical significance of this action is variable.[16] Several tetracyclic antidepressants, including mirtazapine, are potent 5-HT2C antagonists; this action may contribute to their efficacy.

> An overactivity of 5-HT2C receptors may contribute to depressive and anxiety symptoms in a certain population of patients. Activation of 5-HT2C by serotonin is responsible for many of the negative side effects of SSRI and SNRI medications, such as sertraline, paroxetine, venlafaxine, and others. Some of the initial anxiety caused by SSRIs is due to excessive signalling at 5-HT2C. Over a period of 1–2 weeks, the receptor begins to downregulate, along with the downregulation of 5-HT2A, 5-HT1A, and other serotonin receptors. This downregulation parallels the onset of the clinical benefits of SSRIs. 5-HT2C receptors exhibit constitutive activity in vivo, and may retain the ability to influence neurotransmission in the absence of ligand occupancy. Thus, 5-HT2C receptors do not require binding by a ligand (serotonin) in order to exhibit influence on neurotransmission. Inverse agonists may be required to fully extinguish 5-HT2C constitutive activity, and may prove useful in the treatment of 5-HT2C-mediated conditions in the absence of typical serotonin activity.

[1] https://en.wikipedia.org/wiki/5-HT2C_receptor#Function

> Have you ever talked to a _medical_ professional about depression or any mental health issue? They generally don't know what they're doing.

And you think a random stranger knows any better? I know firsthand that the medical profession has serious limitations in its understanding of and ability to treat depression, but no way in hell am I taking some rando's advice over that of any of the many doctor's I've seen.

That makes no sense to me, if you're trying to deal with mental health problems and struggling you're going to be looking for new ideas from any source. Doctors are good at giving garden-variety medical advice that's validated by studies, but there's so many other ideas out there that they're not going to know about. Their background gives them expertise on what medicine says about mental health, not about the human experience itself.

Anecdotally I've been to therapists and doctors that were no help and I've read an article online [1] which was a tremendous help.

[1]: https://kajsotala.fi/2017/07/how-i-found-fixed-the-root-prob...

Strangers on the internet are usually pretty good at helping you self-justify whatever it is you want to do, because no matter what position you take, whether it is a really good idea or not, there is always someone on the internet who agrees with you.

Fine, if that gets you taking action when you're depressed, so be it.

Anyway in discussions like this I feel like what it lost is that you will actually respond to how compelling the thing someone else is saying is. Like, it's not "oh a bunch of opinions, I'll get influenced by one randomly and it's probably wrong". It's "oh, a bunch of opinions, which explain why they think they're right and how well it worked for them, I'll incorporate that into my own understanding".

> Doctors are good at giving garden-variety medical advice that's validated by studies

I've found they're more often than not ignorant of the latest studies, as well. Doctors are put on a pedestal in our society that very few of them deserve. A solid 2/3s of the ones I've seen are over-confident, dismissive, and often peddling out of date information. The rare ones that truly focus on their field and put their patients above their egos are difficult to find and even harder to get to with average US insurance.

How common are the ones that check their ego? 1 in 10?

You're a frontend engineer, not a doctor. You're not qualified to give advice on medicine.

They aren't writing a prescription for op, they are sharing anecdotal data. That's a reasonable thing to do.

Having had a critical infection repeatedly misdiagnosed until I finally went out of my way to pick a better professional, I don't buy the "just have faith in your doctor" argument.

Doctors are more like plumbers than we like to admit. There are good ones and bad ones, and it's hard to tell the difference. They do best when you can give them direction (cooperatively) and when you are willing to get a second opinion.

So what? Everyone has had stories about misdiagnoses or not being taken seriously by doctors, etc. I had a condition that took a long time to get a fix until I changed my doctor and got a proper evaluation done. And that wasn't even for mental health, which the US is not particularly well known for. My doc would come in, listen for maybe 1-2 mins, prescribe some shit and leave. I had to take stuff into my own hands and drive 2 hours to another hospital to finally get something done.

Parent comment is not giving explicit medical instructions. All they're saying is "talk to a medical professional" isn't some miracle advice that always works, particularly for mental health. It's fine to give anecdotes as long as one holds them with a grain of salt.

So any support group is invalid then? AA? Smart Recovery? Addiction is a medical problem, so just talk to your doctor? If you have PTSD, don't talk to other people with PTSD, just isolate and talk to your doctor? If you have depression, don't talk to other people who have had depression, who might make you feel less alone, just talk to your doctor? Think through what you're saying.

Those support groups don't give advice about medicine.

Um, they kinda do. In my experience it's generally not "advice" in the same way a doctor gives it, but it's been more along the lines of, "I took X. Y happened." Not, "You should (not) take X because it (worked/didn't work) for me".

People keep saying we should _normalize_ talking about mental health, and what you're suggesting goes against that. If we were discussing heart health and someone were to talk about their exercise, diet and medication online, would you say, "Hey, wait a minute! You're not a doctor. You can't say that." Of course not. What you're advocating for is an overly paternalistic approach to mental health issues, as if people are too dumb to listen to different viewpoints and come to their own conclusions.

Weird, did you research them?

You are an engineer and not a public health researcher. You are not qualified to give advice on whether consulting a doctor is the right course of action.

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