Antidepressants are over-prescribed, but genuinely help some patients | Hacker News Reader

Antidepressants are over-prescribed, but genuinely help some patients

economist.com

90 pointspseudolus162 comments

My theory is that most people are taking the wrong antidepressants.

I've been depressed for most of my life. It took decades before doctors would prescribe anti-depressants and I struggled trying to find one that worked. It wasn't until I took a DNA test that was specifically developed to help determine if/how one's genes were biased towards/against specific drugs. In my case, all of the ones I had tried so far were listed under "consider alternates" because I have a gene CYP2C19 that metabolizes them faster than other people.

What I & my doctors did, was switch drugs until I found one that worked "good enough". I should have taken this DNA test years ago. It cost me $150 out of pocket.

Out of curiosity, which test/company did you go with? A quick search reveals a lot of options, and I'm hoping you may have done some of the legwork already to determine if one is better than others for privacy reasons etc.?

I don't know the answer, but as far as I know, 23andme seems to be the most focused on medical conditions?

23andme is little more than a grift to steal your genetic data, providing some vaguely interesting, possibly untrue information in return.

DNA privacy has already been defeated. In North America it’s pretty easy to find first cousin level relatives by DNA which really shrinks the target pool especially if you find first cousins from different sides of the family.

The printout I have in front of me says "Medical Diagnostic Laboratories". Their website gives no info about the "pharmacodynamics" test other than one PDF about how to swab the saliva for it.

I had read about it and discussed it with my physician. She ordered it.

0 - https://www.mdlab.com/

Depression is such a generic symptom it's often confused with a disease. I maintain that it is not. There are a ton of things that cause depression, and often psychiatrists just prescribe an anti-depressant and off you go, especially in countries where doctors have an incentive to medicate people instead of curing them.

I've been mildly anxious and depressed all my life, and it's gotten worse in the past few years. Then I learned I might have ADHD, got diagnosed, medicated with a stimulant, and I'm not depressed anymore.

I am pretty sure if I had gone to a psychiatrist instead of investing into long term therapy with a psychologist (that eventually suspected I might have ADHD), I would have probably been given an SSRI and sent on my way. I hate imagining how my life would have turned out, yet the sad stories of undiagnosed ADHD sufferers put on SSRI are very common.

> I am pretty sure if I went straight to a psychiatrist instead of investing into long term therapy with a psychologist (that eventually suspected me having ADHD), I would have probably been given an SSRI and sent on my way.

That's probably true, but a lot of hospitals try to push this dynamic onto doctors/psychiatrists. When my dad (was psychiatrist for 43 years) took a job as medical director at a hospital in Wyoming, they told him when he first got there that they only wanted his role to be prescribing medication, and that they would have psychologists evaluate the patient first, and then determine what medication is needed and then his job would be to write them. I assume the previous psychiatrist was fine with this (he was an unusual guy in general but that's another story), but my dad told them he would not operate this way.

But at the end of the day, the "roles" usually end up being the therapists and psychologists doing the more therapy-focused work, while the psychiatrist makes diagnoses and determinations of which medications may work, and prescribes them because of his M.D.

My brother has been bipolar his whole life, major depressive for large parts of it as well, and generally has had a rough time with mental health. It's taken both medication and life-long therapy to get him to a sort of manageable/live-able baseline.

Lol, it seems like everyone on this website has “ADHD” and “needs” a daily supply of amphetamine just to function.

I think the reality is that everyone benefits from amphetamines whether they have ADHD or not, so working backwards, if you feel better on Adderall, that doesn’t mean you have ADHD.

Not sure how you got that from what they wrote. They said their psychologist suspected ADHD based on their symptoms and then prescribed medication for it.

That is mostly correct: psychologist do not prescribe, psychiatrists do, as they are in fact medical doctors.

In my case psychologist made the suggestion I had ADHD after 2 years of therapy, so they knew me pretty well by that point. It all made sense to me, and I went to a psychiatrist to get diagnosed and medicated.

Had I gone to a psychiatrist directly, they probably would have prescribed an antidepressant without spending 2 years getting to know me.

Haven't there been studies that people without ADHD do not benefit from amphetamines? Not to mention, there are meds that aren't amphetamine- Ritalin isn't one!

While not an amphetamine, Ritalin is a stimulant that neurotypical might use and abuse exactly like amphetamine.

That said, GP is talking out of their arse and is perpetuating one of the biggest reasons I waited until I was 35 to get diagnosed: I too thought ADHD was bullshit until I was in a position at looking at my life, my difficulties and how other people were living, and it was pretty obvious I was missing something.

This ignorance surrounding ADHD is widespread, and people think we take amphetamines to write code 80 hours a week without taking a break.

I take amphetamines to have the energy to work 4 hours a day and pick the trash off the floor while not hating myself, so comments like that one feel quite ignorant, yet you can find them in every HN thread offering their misinformed 2 cents.

This is not a good faith comment

> There are a ton of things that cause depression, and often psychiatrists just prescribe an anti-depressant and off you go, especially in countries where doctors have an incentive to medicate people instead of curing them.

For what it's worth: toxic work culture (=absurd amounts of overtime, lack of mandatory PTO, lack of legal protections for people with mental health issues compared to those with physical health issues) makes it often impossible to actually cure people, not to mention global impacting issues such as unaddressed climate change, the lackluster response to the pandemic or open warfare.

To actually remove these contributors or causes of depression and other mental health issues, we'd need a society-wide reform.

In the US, there are significant legal protections around mental health. ADA applies to mental disabilities.

And I’m very glad it does. I need accommodations for me to work full-time.

Yes, a lot of times people think depression is an illness whereas in fact it is a symptom. It was actually scary to see how easily you can get antidepressants once you mention depression and anxiety. I refused any type of medications because I don't believe there is anything wrong "technically" with my brain, if you gave me $10k it would be perfectly capable of producing hormones of happiness - see no medications were consumed but just the idea of having more money made the brain produce chemicals, so changing the perception of how we see things is crucial imo. I believe only a fraction of clinical cases require antidepressants e.g. major depressive syndrome etc in most cases therapy is the way to go but it is expensive and people don't generally like it they would rather take medications. I think I've made a great deal of progress just being in therapy, practicing meditation, healthy diet etc

Being sad or sad often is not depression. Depression is a varying level of not being able to be happy even during happy events.

The comorbidity of anxiety/depression and ADHD can certainly be hard to disambiguate so I’m sorry it took so long to find the right treatment, but it’s also great that you’ve got it now. I do want to point out that a psychiatrist would perform a targeted history of your presentation and mental status exam, and might very well have provided the “correct” diagnosis much sooner—these people do more than prescribe medications on their first hunch. It generally wouldn’t take two years to do a generic review of mental status symptoms.

A GP on the other hand might be more pressed with less time to prescribe an SSRI or medication of a related class and put in a referral.

There’s wide range of anti-depressants and many different treatment strategies, including dosage variance. Metabolisation tests may be helpful in some cases to determine if a drug may behave in unintended ways in your body but that doesn’t mean the drug isn’t part of a valuable treatment strategy for you.

The process of experimenting with different treatments for mental health conditions isn’t about finding which drugs your body is most capable of metabolising, rather, it’s to find which treatment meets your mental health needs. A drug may have severe physical side effects but address your mental health symptoms so effectively that the treatment is worth it: a gene test won’t highlight that.

Unfortunately, we don’t really know why some treatments work for some people and others do not: if you’ve got dozens of options, and not enough time to test them all, then a dna test to rule out a bunch is probably going to be helpful (since you’d have to skip some anyway!) but it’s definitely not a case of, everyone should do these tests before deciding whether a treatment is right for them.

1000% get sequenced! Should be step number one for everyone. It’s now $200 for a high quality whole genome sequence where you can do all DNA tests simultaneously as well as future tests being developed. We’re walking bags of pathogenic rare conditions.

What DNA test did you take?

The core finding in the article is: for 15% of people antidepressants provided large benefits independent of the placebo effect.

What this suggests to me is the syndrome we call "depression" has multiple root causes, and current antidepressant medication treats at least one of them, but not all of them. Identifying those causes and finding ways to test for them could bring huge benefits, both in identifying people who would benefit from drugs, and avoiding unnecessary treatments for those who would not.

> What this suggests to me is the syndrome we call "depression" has multiple root causes

Pretty sure in 50 years we'll see "depression" the same way we now see "hysteria" in 1800s/early 1900s, aka mostly whack diagnosis that grouped a lot of completely unrelated things under the same term

I was briefly suicidal about 20 years ago, took anti-depressants for a couple of years, never needed them since. I can't say if they "worked" in a biochemical sense — perhaps the only affect was placebo — but they did keep me sane until my life circumstances improved. The brain is a very complex organ we still only vaguely understand, so "fixing" it is still very much a primitive response.

Yes, the problem is in the "until my life circumstances improved". In your case they either improved on their own, or you don't talk about the possibly large amount of work you did to improve them. In my understanding (but it's not my field) the criticism is precisely of when antidepressants are used without a proper plan on that side.

I'm picking up a theme about the US health care system - that doctors respond to conditions caused by environment with a drug.

Our lifestyle (activity) is unhealthy, our food is unhealthy, our houses are nice but we don't get out of them, our relationships are unhealthy, even our culture creates anxiety. I speak for myself, but also everyone I know.

This sounds like the correct way for these things to be utilized. In your case, you were approaching a bottom so in so many words, you were at the end of the line and the only way to go was up (if you wanted out of the predicament).

Where the prescriptions fail imho is with people that are nowhere close to bottoming out. They are in the murky middle and then get a bunch of scripts. They are not near destitution, so their prescriptions end up being perpetual. Taking antidepressants and other medication, and then going to therapy for years constantly talking about how much it sucks to be depressed about this and that means you are on a pathological treadmill. In sports, a “treadmill” team is good enough for the playoffs, not good enough to win a championship, not bad enough to get a top 5 draft pick that could change the whole team. They are stuck in the middle. Eventually treadmill teams realize they need to bottom out and trade most of their team so they can suck for a few years and rebuild with great draft picks (the crappier you are the, the better draft picks you get).

Bottoming out is, for better or worse, one of the most effective methods of snapping people out of an addiction.

I think it is underutilized when it comes to other issues. If you say your life sucks, then lose the job, lose the money, lose the friends, get homeless, and sleep out in the cold. Then if the natural will to live a better life doesn’t kick in, we’ll hospitalize you in a mental institution. Then we’ll try the medication. I’m pretty sure for most people, especially this demo of privileged tech workers, will at some point realize “hey my life ain’t that bad”.

In Tech we call this “fail fast”. Test your theory on how much you think your life sucks by making it suck even more, and test it quickly. Then you’ll get your perspective.

I have a coworker who got caught in that moddle ground as a teenager and is now middle-aged and still in an ssri. At some point can the brain still return to normal function if the chemicals are removed? Playing with feedback loops in my own body would terrify me. I suspect that is a major reason so few want to be in endocrinology. Its horrifically complex.

I’d look to addicts and alcoholics that turn sober. Their feedback loops are way out of whack from years of drug/alcohol abuse. Yes, you do return to normal. It’s just that addicts and alcoholics cause so much social and legal issues that they bottom out of their psychological issues in a more serious way.

If you are on a drug cocktail that mostly doesn’t let you fuck up your entire life, there will be no major turning point to snap you out of it. Clinically, this is a massive success. They are keeping people from being a complete disaster. However, the opposite of “not a complete disaster” isn’t necessarily “tremendously peaceful and happy life”. It can truly be the murky middle.

It can go on forever in those cases.

That's very much a case of "working as intended". Most cases of depression aren't chronic, but can be self-perpetuating (low mood leads to a hard time fixing the things that make your mood low, which leads back to the low mood).

Anti-depressants can break that cycle long enough to let you get your stuff together to the point the cycle stays broken.

> Anti-depressants can break that cycle long enough to let you get your stuff together to the point the cycle stays broken.

Cycle-breaking is the selling point of using psychedelics for mental health treatment.

From what I can gather they're far more effective than "traditional" anti-depressants.

Early studies for new therapies are often much more promising than the therapy actually turns out to be once deployed on a mass scale. I absolutely agree that psychedelics should be explored as a medication of choice but some promising early studies don't mean that antidepressants like SSRIs no longer have a place or that the early promise will prove out in the long term.

I just want to plus one this anecdote. I had a traumatic experience that led to my getting stuck in a very bad mental state. It became a cycle, where I didn't have the energy or willpower to do the things that could possibly have pulled me out of the pit.

Antidepressants gave me the mental space to break the cycle and get things back on track. Placebo or not, my mental health steadily improved once I started taking them, and soon I found myself able to get back to exercising, eating healthy, and doing the other things that led me back to a healthy life.

Edit to add: I am glad they were available when I needed the help, but I hope to God I am never in that bad of a mental state where I feel like I need them again.

I had anxiety attacks constantly (chest tightness followed by passing out) in any sort of stressful environment. I tried for years to conquer it with mental toughening, but recently my doctor prescribed me Zoloft and it has completely solved that for me. It’s like a miracle drug. A side effect? Noticeably improved moods. I was certainly not substantially depressed, but my balance of moods is definitely shifted towards positivity and I’m just less moody. So I definitely believe they can be a tool in the fight.

As someone taking Lexapro for similar reasons, do you have any plans to taper off of Zoloft? I tried to stop taking it cold turkey once and had wild side effects ranging from fatigue to the inability to keep my balance standing up.

My psych seems to be okay with keeping me on it indefinitely but I'm not sure how long I _should_ be taking this stuff.

Take it as long as it helps you.

Strange, Lexapro is typically one of the easier SSRIs to stop taking; it has a long enough half life that it tends to be self-tapering.

It's certainly possible to do a slow taper off it, though. In general there should be no super long term side effects to worry about though.

If you absolutely insist, your psychiatrist would probably help set up a tapering schedule.

Do whatever feels right for you. There are some people for whom there is a psychological cost to being on medication and medication for them is a step towards being "normal" but for many other people (like myself) medication is a tool I'll continue to use for as long as it feels helpful.

That said, if you do wish to stop taking medication like Lexapro or Zoloft, try to frame it as an experiment in finding the ideal dose for yourself: you hope it'll be 0 but it may not be. Stopping cold turkey is a very bad idea for the obvious side effects you experienced, but you're also missing out on the opportunity to understand whether you can live well without the medication (i.e: your entire quitting Lexapro experience becomes consumed by the horrible side effects, rather than the change in your mental health, which is difficult to measure when you're suffering an inability to stand up right).

I am not a doctor or the parent commentor, just a Zoloft consumer, so take this with a spoonful of salt, but... the standard dose of Zoloft is anywhere from 50mg to 200mg: if you're on 200mg and feel that maybe now is the time to come off Zoloft, then gradually reducing down from 200 to 150 to 100 to 75 to 50 to 25 to 0 will give you many helpful checkpoints to determine whether the medication is required, e.g: if you get down to 100mg from 200mg and start to struggle, you know that 100mg isn't enough, but 200mg is more than you need, so maybe a good new dose for you is 150mg. Repeat every time you feel like quitting. Swap those numbers for whatever Lexapro's dosage range is.

No plans to taper off, I’m much happier with my quality of life on it and the side effects are pretty manageable.

I have had similar experience with mirtazapine. As a bonus I sleep much better now.

Despite the the title itself not being news, there is an insight in this (short) article and it IS worth actually reading IMHO.

https://archive.ph/vmmFi

I wonder if anyone is doing a study into the particulars on the three groups to try and find common characteristics to guide future prescription? The cynic in me assumes not as that would reduce demand so why would a manufacturer fund such a study? But perhaps I am over cynical.

Speculating wildly for a moment, think that misdiagnosis is one likely reason. Maybe anti-depressants work on depression (the disease), but do not work on (say) CPD (where depression is just a symptom). Of course actually correctly diagnosing people will be time consuming and expensive. And I personally am not convinced we actually have a good grip on what diseases exist in mental health but that is another whole discussion...

> And I personally am not convinced we actually have a good grip on what diseases exist in mental health but that is another whole discussion...

If possible, can you go into it a bit more and/or link some further reading?

Part of the reason for the disparity is that people's genetics can drastically influence what effect particular drugs have. Switching drugs is a pain as one is supposed to taper off the old one, then switch to the new one and wait 4-12 weeks for the new one to take effect. If one drug works "good enough" then you're unlikely to want to even try a different one.

I finally took a DNA test last year after reading about it (a "pharmacodynamics" one that your doctor has to order). Reading the results showed that all of the antidepressants that I had tried in the past were ones that I either had a gene to metabolize too fast or another gene that said they'd be ineffective for me.

The key problem is that even in 2023, we barely have an understanding how the human brain works. We know from trial and error that some stuff works pretty well, e.g. areas where the natural water supply is high in lithium have lower depression rates [1], herbs and plants with psychotropic effects (LSD, mushrooms, cannabis, ...) - but we barely know why these work or why some people with the same ethnic background, symptoms etc. respond completely different to the same amount and type of anti-depressant (or other mental health impacting) drugs.

The reality for a lot of people with mental health issues is that they struggle for years until they finally manage to find something that works for them.

And obviously it didn't help either that research on whole classes of drugs was pretty much outlawed and non-existing for the last decades "thanks" to the war on drugs. The time lost to that crap is seriously holding us back.

[1] https://pubmed.ncbi.nlm.nih.gov/32716281/

Antidepressants can be wonder drugs for some people but in my case they made me manic as hell and ruined my life for a few months. Make sure you get screened for bipolar before you go on them.

If your healthcare system is private patients become customers and the customer is always right. If they want pills the doctor will give them. Antibiotics, sleeping pills, painkillers, antidepressants.

There is significant over-prescription of ant-depressants in the UK NHS as well. As far as I can tell at least partly because the health and social security system doesn't have the capacity to treat underlying causes. Some of the underlying causes are of course poverty and insecure employment neither of which is amenable to a medical intervention.

Waiting times for any kind of talking therapy are huge and even when a place is available it will often require the patient to travel long, expensive, and awkward distances which alone makes it impossible for people on low incomes.

I probably would have killed myself if not for antidepressants. I cared for my elderly grandparents through the end of their life. During that time I saw a therapist to talk about my depression that kept getting worse as I slowly watched them die. I kept asking her to prescribe something for me but she said she didn't have the ability to write a prescription. What she didn't tell me and what I didn't learn until my third call to the suicide hotline is I could just ask my primary care physician. I thought I needed a therapist to sign off on it but it wasn't needed at all. I ended up quitting her practice for not bothering to tell me I could just ask my doctor for a prescription we ended up having a fight because she argued that I didn't need them. Meanwhile 3 weeks after I got them I was no longer suicidal. Anecdotally, people say antidepressants are over-prescribed but I've been on that prescription now for 8 years, the last of my grandparents passed two years ago. It is my personal opinion that talk therapy is what is over-prescribed because it didn't do a fucking thing for me while a $7 dollar a month prescription solved in a month. Don't let people tell you what you should do to stay sane, that's between you and your doctor.

I've only read the headline, but isn't this the consensus already?

Full disclosure: I'm on antidepressants and probably don't really need them.

If you care enough to wonder and comment, why not read the article?

Paywalled. Or requires registration. I don't care which.

https://archive.ph/vmmFi

Not really. I haven't heard a explanation that is all that credible about why mental illness rates are skyrocketing like they have been (quick Google pulls up this chart, you can find many others[0]). The idea that a large percentage of children are mentally ill is taken at face value but if rates of say asthma were rising at the same pace we would probably be restructuring society to prevent it.

[0]https://www.whitehouse.gov/cea/written-materials/2022/05/31/...

There seems to still be this notion that mental health is froofroo stuff and if it’s all in your head you need to just toughen up. So either it’s chemically based mental illness in which case you take a pill or it’s nonsense.

Antidepressants can help some people with chemical issues but will do little to nothing for people without them.

"and if it’s all in your head "

Erm yeah, mental problems are literally all in your head. That doesn't make them less real, though. And of course, toughen up is a stupid thing to say from someone not having those problems. (on the other hamd, you can take I am sick as a excuse to not make an effort anymore)

And if the chemicals are not in order still leaves the question whether that is just the symptom or the root cause.

What I mean is, that when someone has a shitty life and is therefore depressed, then his brain chemicals are probably not look good. Pills still might help this person to transition back, but this won't be sustainable, when the root cause does not get fixed.

Agreed. Sometimes though the unofficial diagnostic for possible chemical issues is that there is no obvious cause in one’s life for depression. If your life is great and you don’t feel it there might be something wrong.

> Erm yeah, mental problems are literally all in your head.

Well, everything you experience is literally in your head, so it's a bit useless observation. What matters is whether or not you can think the problem away, which for being depressed is about as possible as for a broken arm.

> What I mean is, that when someone has a shitty life and is therefore depressed, then his brain chemicals are probably not look good.

Yes. But in many other cases, brain chemicals are not looking good because of some other, more permanent issues, like genetics, or environment in which one grew up.

> Pills still might help this person to transition back, but this won't be sustainable, when the root cause does not get fixed.

There may not be a root cause. If one's stuck in a feedback loop of "bad mental state -> shitty life -> bad mental state -> ...", it doesn't even matter much what initially caused it all those years or decades ago. And again, in some cases the root cause is just permanent.

A wheelchair is a good analogy to mental health medication. A wheelchair will help people move around regardless of whether they were born without a leg, lost their leg in an accident, became paralyzed from waist down, or had a rough fall and need to give couple weeks or months for their legs to recover. You don't tell the person without a leg that they should think about transitioning off the wheelchair. You don't deny a wheelchair to a person with temporary loss of mobility from a bad accident. Some people will need it permanently, some only for a moment - but if they all have specific mobility problems, the wheelchair is there to reduce them.

"if they all have specific mobility problems, the wheelchair is there to reduce them. "

Yes, but if a person with 2 normal legs insists on continuing to use the wheelchair after an accident - he or she will allways remain dependant on it (muscles go away very fast and it is hard work to regain them) and not be able to walk again on their own feet. Same with antidepressants I figure. It will be hard, to not use them anymore.

Diet, lack of exercise.

It isn't "skyrocketing". People are willing to discuss it nowadays. When I was younger, the attitude of those around me was to "be a man" and "just suck it up". The younger generations are unwilling to put up with the misery and abuse that older generations felt obligated to endure.

In some large cohorts (ex. white liberal women [0]) nearly half of the members are mentally ill or identity as such. Any illness having that level of afflicted should be a major concern, we should pull out all the stops to find out why (and given it's a mental illness, it really makes me rethink democracy). People feel comfortable to talk about it more is a cop out, either these aren't really illnesses (eg. having some level of anxiety isn't abnormal for humans or other primates, some percentage of people on anxiety medication probably are on it without a good reason) or there is some environmental cause we are missing, my guess is it's a little of both.

[0]https://wibc.com/108211/pew-study-white-liberals-disproporti...

Yes not really new.

There is new gusto for a couple of reasons

1. First and foremost antidepressants prescription rates are rising..and are rapidly becoming the most common medication. There are programs to reduce psychotropic prescriptions in children and those with intelligent disability but instead this is becoming a shift to AD.

2. Increasingly awareness that people aren't coming off them. We perhaps don't quite have system for drawing people off medications (hyperbolic dosing probably would help with switch to longer acting medicines).

3. Recognition of side effects especially sexual ones that take up to 6 months to resolve. Some claim never do. Hard to judge this but overall it's clear that patients don't feel they fully appreciated and where informed of some side effects. To be clear there does appear to be reduce sexual function up to about 6 months after usage in some. Indefinitely seems unsupported by facts but you will be hounded for saying so on some social media.

4. Disillusionment with pharma companies really enough said here.

5. Increased rates of supportive counselling Vs psychotherapy. Reducing the cost effectiveness of AD.

Thanks, I should have read the article first and keep my mouth shut. Although you've provided a great summary because of my question.

>> Recognition of side effects especially sexual ones that take up to 6 months to resolve.

For men, if it's the "can't finnish" side effect, take selenium supplements. This may not work while on the ADs. Beware it can influence your PSA level.

Source: anecdote from a friend.

My understanding is that the main side effect is loss of desire and libido. Sex being less pleasurable is another reported one which seems to be in a significant part linked to the previous one.

The two both influence each other. It gets tough to do the work when you're pretty sure there won't be a payday.

OTOH how many people with a healthy sex life are on antidepressants? I want data!

I've been using milk.

https://www.dailymotion.com/video/x2qvim6

It's not the lack of milk that's the problem. It's the getting rid of the milk.

Awesome. Say thanks to your friend.

I have this issue. Which is weird if you still have a high libido and want some relieve.

> I've only read the headline, but isn't this the consensus already?

If only there was a readily available and easily accessible source of information that expanded upon the headline and had the potential to answer further questions on the topic…

You mean the linked paywalled article? Not that "readily available".

CTRL + F archive

There's usually someone linking a non-paywalled version of the article on HN :)

https://news.ycombinator.com/item?id=34337874

I had taken Paxil for the past decade and stopped late last summer. It had some effects I enjoyed, but it also had so many bad side effects that frankly the doctor that prescribed it to me never even mentioned. Lower libido, lower testosterone, weight gain, sometimes making me more apt to make a rash choice etc. It was also literal hell to taper off of, and I don't say that lightly. Brain zaps, restless legs, insomnia, flu like symptoms, minor sexual disfunction etc. It took 2 months for RLS to go away with some help from some supplements like Ashwaganda and Magnesium. However now that I'm fully tapered, I still don't feel depressed, I've lost 10lbs and my testosterone and libido are starting to come back.

I like to think Paxil helped me in the past but I'm not entirely sure. My main problem is the lack of transparency upon it being prescribed. I don't think my instance is unusual.

Tried a couple (citalopram, sertraline) that didn't work for me. The first did make me gain a bunch of weight though, took years to work that off. Also had buproprion, which was useful & stimulating at first (as expected) but I seemed to build a tolerance really fast. So I gave up. Actually my primary doc just refused to renew my Rx and so I went cold turkey, then got rebound depression, that was fun. I know there are 8+ more SSRIs I could try, but my ADD (undiagnosed) is probably a bigger problem anyway. Its on my TODO list to go to a psychiatrist to get that all sorted out, for about 4 years now. Will need something to get a job again though.

Another problem is that some drugs are artificially illegal to prescribe like medical cannabis. Doctors run out of options and prescribe anti-depressants off label for chronic pain rather than safer cannabis.

I know someone suffering from chronic pain who tried to commit suicide multiple times after being on anti-depressants. Fortunately medical cannabis has been legalised and that person now thrives. Caveat is that here it is only available on private prescription and costs a fortune. I wonder what happens if that person gets made redundant and won't be able to afford it anymore.

Those graphs in the article look too close to placebo. So I wonder why antidepressants are still prescribed to treat any kind of disorder and not only, well, genuine psychogenic depression.

The thing is psychogenic aspect is overrated. In reality, there are multitudes of other pathologies that may cause a condition. For instance, metabolic dysfunction, poisoning, Lyme disease. And if one treats only the consequence and not the cause then the probability of a successful recovery becomes negligible.

Should we do more comparisons to no treatment? (Placebo is not "no treatment", that's why we have placebo effect.) Three cohorts, medication, placebo medication, no treatment. There must have been studies like this?

This metastudy seems to say they have no evidence of a placebo effect, though. https://pubmed.ncbi.nlm.nih.gov/12535498/

> Those graphs in the article look too close to placebo. So I wonder why antidepressants are still prescribed to treat any kind of disorder and not only, well, genuine psychogenic depression.

Another article goes deeper into this issue (ie. why do meta-studies show a statistically significant difference, but the difference is so small?)

https://awaisaftab.substack.com/p/the-case-for-antidepressan...

Holy crap, this general headline probably captures the vast majority of all interventions and strategies for everything. Replace "microservices" for "Anti-depressants" and you could probably get the same for companies.

This is not to say the research is bad. Quite the contrary. The research is to find the nuance and most patients/companies can't wait for that before they need something.

The research has shown unequivocally that the benefits, such as they are, for the majority of people derive from the placebo effect. It's only in the very extreme cases where the effects genuinely exceed placebo. Irving Kirsch alone has hammered this for many years...

I don't know when the lawsuits will finally begin, but they're going to be epic.

Ultimately, they'll pay a relatively small fee. Their insurance will cover some. In the end consumers will pay the rest.

It's a great business model. Shady but effective.

It's shocking to me how few people realize that anti depressants very rarely outperform placebo. I've been arguing with people about this for years, because the evidence from RCTs really has been convincingly bad for a while now. I'm starting to feel like psychopharmacology is a lot like academia, where the real force of change is a generation taught X dying off.

>It's shocking to me how few people realize that anti depressants very rarely outperform placebo

very rarely?

>Findings

>We identified 28 552 citations and of these included 522 trials comprising 116 477 participants. In terms of efficacy, all antidepressants were more effective than placebo ...

https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

> All antidepressants were more efficacious than placebo in adults with major depressive disorder

1 in 4 American adult women take anti-depressant drugs. Do they all have major depressive disorder?

> Do they all have major depressive disorder?

Given that women have to bear an utter majority of the workload summarized as "care work", anything from raising children over household chores to caring for elderly relatives, on top of female-specific health issues like painful periods or endometriosis (10% of women [1], and that is before under-diagnosis or late diagnosis comes into play [2]), it makes sense that a lot of women end up with depression-related symptoms. Other societal factors that increase load on women (like the drug crisis, absent fathers, rampant sexism and misogyny in society, the recent barrage of threats to womens' lives and reproductive health) also come as an additional risk factor.

Additionally, as women have entered the work force over the last decades for a number of reasons, it also makes sense they now have rising rates of work-related mental health issues like burnout and depression.

And what also must not be forgotten is a severe under-diagnosis for mental health in men. Barely half the men that self-report symptoms of depression or other mental health issues actually seek out help [3], my personal guess is that this is to a large degree because the historic image of "male-ness" outright ignores mental health issues and labels men that seek help for these as "weak", which has been shown for PTSD in var veterans. Women have it "easier" from social expectations, which may help to hide the fact that, were men equally invested in their mental health, they'd end up at the same ratio of depression!

[1] https://www.who.int/news-room/fact-sheets/detail/endometrios...

[2] https://www.forbes.com/sites/alicebroster/2020/08/27/why-it-...

[3] https://jamanetwork.com/journals/jama/article-abstract/24346...

Are you being intentionally dense? Antidepressants are also used to treat most anxiety disorders, including GAD, OCD and PTSD.

As well as depressive disorders other than MDD.

Antidepressants being overprescribed is an issue entirely unrelated to antidepressants working better than placebo.

What's your argument here exactly?

Right, a metastudy where one of the stipulations is:

"We excluded ... trials that ... included 20% or more of participants with ... treatment-resistant depression"

And still the result is:

"46 (9%) of 522 trials were rated as high risk of bias, 380 (73%) trials as moderate, and 96 (18%) as low; and the certainty of evidence was moderate to very low."

And the cognitive bias is towards efficacy. We've raised and taught two generation of people who believe in a thoroughly defunct theory of 'chemical imbalance'. SSRIs are conceived from this idea and presented as evidence of this idea, but it simply does not hold up under scrutiny [1].

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

> Right, a metastudy where one of the stipulations is:

>"We excluded ... trials that ... included 20% or more of participants with ... treatment-resistant depression"

That seems reasonable, as long as 20% isn't the baseline level of "treatment-resistant depression". If you're going to do a search for all anti-depressants studies, you're bound to turn up some studies that are researching-treatment resistant depression. If you're trying to study how anti-depressants behave typically, it makes sense to exclude the extreme examples, just like if you're trying to study whether an anti-cancer medication works you want to exclude the cases where the patient was on his deathbed.

Why would there be lawsuits? Studies consistently show that antidepressants are statistically better than placebo[1]. Sure, it might not be by much[2] but it's not exactly snake oil either.

[1] https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

[2] https://www.bmj.com/content/378/bmj-2021-067606.long

Generalizing to all compounds marketed and prescribed as "antidepressant", that may be true. However, there are compounds that do mitigate conditions associated with clinical depression.

It's more about not having the tools at the time to effectively treat real conditions in people, and whether making people okay with things even if it robs them of other capacities was the only acceptable, pragmatic, and even compassionate choice.

I think the lawsuit will have many high bars, but at the very least I hope it begins the end of the practice of prescribing to children for behavior control.

~15% people with depression see very large benefit from antidepressants, but and the general population does see some benefit. So the drug companies aren’t at fault any more than makers of antibiotic are at fault when someone prescribes them for a viral infection.

The problem is it’s very easy to prescribe something and much harder to verify it’s working. Just look at everyone who genuinely believes in homeopathy etc that are dependent on the placebo effect. You hand out a drug and people say it’s making a difference in their life so you keep prescribing it.

This is a misunderstanding of the research.

Firstly it is making the fallacious assumption that the shift applies via a large improvement in extreme cases rather than a small improvement to each case.

Secondly, there are flaws in the study methodology. Depressive symptoms come and go by nature, and people seeking pharmacological treatment will more often than not be at a lower point in the cycle, so it is only natural that they will improve in time on average. There is also the problems with the fact that depression is assessed via self-reported questionnaires which have a ton of issues.

To say "The research has shown unequivocally that the benefits, such as they are, for the majority of people derive from the placebo effect" is unsupported by the evidence.

>the research has shown unequivocally

Citation needed. And it most certainly has not showed that.

Every evening, owners (who were on antidepressants) would put dog in solitary for the night. They had a special room for this. Dog found it very stressful.

Eventually dog, knowing what horror was coming, would get upset as evening approached.

Owners, on the advice of a dog-psychiatrist, put dog on antidepressants to cure the upsettedness.

It's emblematic of something.

So on the level of the dog, everything else being equal, is it better to have the medication or to suffer?

Or option 3: let dog sleep in owner's bed.

My understand is that a dog's psychology is that of a pack animal, and that the stress of being put alone in a room every night is the stress of being separated from "the pack." Being separated from the pack equals the looming threat of death—to a greater or lesser extent—for a pack animal.

What this whole scenario illustrates is that the dog's suffering depression was due not to any chemical imbalance but to it being in an environment radically unsuited to its deep-seated psychology. So, the dog's case, I would argue, is a case of anti-depressants being over-prescribed. The people were being cruel to the dog. They should have stopped being cruel.

I'm writing all this because the dog's owners were on anti-depressants too, presumably to ameliorate their suffering. Perhaps they've created just as bad an environment for themselves as they have for the dog. Is it better for them to have the medication or to suffer? I say, that may be a false alternative.

I was treating the dog as an analogy for us, or maybe for children - in environments that aren't particularly suited for us having good mental health, etc. And the giving the dog antidepressants as an analogy for a prescription. If it's a literal dog then yeah.

I would certainly choose suffering, no question.

ADs have helped my friends but didn't help me. Other medication did help however and for that I am thankful. It gave me breathing room, enough to reboot my career and focus on important things.

So it’s like antibiotics. Sure they’re devastating for many people’s long term gastrointestinal health, but it does save some of them, so we make the trade off.

I am a doctor. ALL conversations in HN about mental health go overboard due to two reasons: either generalisation of a N=1 case or trying to apply in practice large scale statistics.

Reality lies somewhere in the middle, that is ADs are neither garbage nor life saving for all. It is absolutely personalized

How are we all not n=1? If we don’t share the same fingerprint how are we supposed to have the same chemistry? And you’re a DR? Sorry but scary. Like me saying all Dr’s are killers or all pigs are cops no? Must be nice weather over there

I have trouble making sense of your comment.

You are replying to someone explaining that their professional experience shows that the answer can be neither generalising anecdote because what works for one will not necessarily work for another nor simply broadly applying statitics because, to oversimplify, something which works perfectly for 20% and not at all for 80% as a terrible average rate of success but is indeed what you want if you are amongst the lucky 20%.

What are you complaining about in this take exactly?

My favorites, all doctors are small and nobody knows you’re a dog on the internet!!! Yeeeee hawwww, sorry, just retired yesterday and feeling lively:)

I'm not following. Why is being a doctor scary? And why do you believe or suggest doctors are killers?

The problem is incorrectly generalizing personal experiences to a population. You've implied that because there must be a relationship between some people, that relationship is the same for all people. You've reduced the complexity of all of human health to a single factor - being human.

I think this is a good example of misunderstanding the purpose of both science and medicine.

Same chemistry different DNA. Based on the 1000 genome each person has roughly 150 known pathogenic rare mutations. And vastly more currently unknown pathogenic. People inherit ~2 to 3 million SNPs from a collection of 700m SNPs.

So doctors are looking for rare conditions in 1 of 10 people, where we all have rare conditions and a lot of them. We are walking bags of rare conditions. Thankfully there are direct to consumer While Genome Sequencing which is pretty easy to find your SNPs and look up which ones are attached to studies about being pathogenic.

I figured out that I have pathogenic TNXB mutation myself despite the gaslighting of many doctors for many years and WGS confirmed it.

It’s a totally different way of doing medicine that bypasses doctors.

Interestingly enough one of the treatments for my specific mutation is one sub class of anti depressant.

Thanks for defending AD. They help a little but it's better than nothing.

The new problem is how internet people encourage others to self medicate with psychedelics. Everytime there is a trial study, you can read a lot of them.

> The new problem is how internet people encourage others to self medicate with psychedelics.

This is a seriously annoying and recurring issue on HN. It's the "just hit the gym, bro" equivalent of silicon valley.

Agreed. It's so idiotic because psychedelics only have an effect in the right setting, and clinical psychedelic therapy is all about establishing that setting.

Doing it alone, or with some burnt out druggie friend is not likely to work except by pure accident, and making it worse is just as likely.

This claim needs some data to back it up.

Which one, the part that set and setting matter? Read basically any paper on psychedelic therapy.

That psychedelics can worsen mental disorder?

Psychedelics can help you process bad experiences, and it can generate new ones. You can unlearn unhealthy biases or gain new ones. The papers tend to discuss this.

> Doing it alone, or with some burnt out druggie friend is not likely to work except by pure accident, and making it worse is just as likely.

This claim, that doing it alone is unlikely to work, or likely to worsen your situation.

> That psychedelics can worsen mental disorder?

That sentence is not the same as the previous claim.

That all derives from the fact that set and setting are crucial.

And I didn't suggest worsening was likely, but I think it's about just as likely as stumbling into a real treatment effect by accident, which is what I said. I'm not sure what data exists on the relative probabilities here, probably fairly little.

Most of the time, you'll just achieve nothing at all other than maybe an afterglow that makes you think you're better for a couple of weeks.

I've used a lot of different psychedelics in different settings over the years(pribably somewhere around 100 experiences with something like 10 different psychedelic drugs), Exactly once I've had a concrete, non-temporary improvement in mental health. Another time I had such a bad experience I took me months to properly recover.

Most of the times I felt like progress was being made, but it turned out just to be an afterglow effect that quickly went away.

If your symptoms subside for a couple of weeks, and you repeat the experience every couple of weeks, it’s hard to see how this is much different from taking SSRIs. They certainly don’t claim to cure anything either.

What would be good data which is actually practical and ethical to get? I hope no review board would approve a plan of "group A will have a professional therapist following protocol XYZ, and group B will be handed a dose and a printout of a reddit thread and told to have fun"

Sometimes we don't have good data for good reasons.

If they require the right setting, it's probably because they're not a miracle drug.

No one in this thread has said they're a miracle drug so I'm not sure why you're bringing that up.

But no, they're not.

I meant to say that they're not as good as antidepressants

This is such a weird thing to say, I'm kinda fascinated by it.

I once had a life-saving surgery, which was a relatively new procedure and that I felt could sort of reasonably be called a "miracle surgery" (to make an analogy to your comment).

The surgery required all sorts of right settings- a sanitary operating room with lots of light and climate control and space for multiple medical staff to be in the right positions and complex after-care that involved medications, IVs, monitoring of vitals in a specific setting.

I would never say "since my surgery required the right setting, it's probably because it wasn't a miracle surgery". Nor even, "since my surgery required additional medications..." or "since my surgery required required subsequent physical therapy" or anything else.

Lots of treatments for lots of conditions are going to involve a mixture of many modes of treatment, or only be successful if multiple independent things are done in unison.

I think every person is in charge of their own health. We can’t blindly follow advice based on credentials of others.

Sure, you're responsible for your health but don't use that as an excuse to ignore or dismiss scientific evidence. I guess you could ignore it, as long as you aren't harming anyone else, but it still seems like a bad idea.

I think that’s part of the problem. We have very little understanding of the mechanisms of depression and how ADs can help or harm that.

No, of course not - by definition, advice is advisory only.

But we can and should default to trusting advice from reputable people over hearsay; credentials inform our assessment of how reputable they are.

> advice is advisory only.

The last three years would like a word.

> But we can and should default to trusting advice from reputable people over hearsay; credentials inform our assessment of how reputable they are.

Tell that to the doctor 50 years ago that recommended his favorite brand of cigarettes. Or the experts that made the food pyramid.

> The last three years would like a word.

There is nothing unusual about the last three years. Public health measures have frequently come with stiff penalties, since the beginning. “Sin taxes”, drug prohibition, water quality and vaccine mandates, etc.

Yes, and no. If your health issues can impact the health other people, it's no longer just your problem to be in charge of. And without proper training, you can't manage your bigger health problems without help, either mental or physical.

Antidepressants were weird for me because they just made me temporarily satisfied with my life going nowhere and working a terrible job that I hated. Also when I got off of Paxil I felt like I was being dropped down an elevator shaft for months.

Turns out I just needed to succeed in life and suddenly I’m not depressed anymore. I was keenly aware of what a loser I was and through marriage and a small amount of amphetamines am doing pretty well now.

Chiming in with an anecdote that aligns with yours. I've never used antidepressants but my sense of self-confidence and "happiness" is so highly correlated with my level of mastery and control on my life progression that I now ask myself the same question when I'm feeling vaguely bad: "what is going on in my life that I have the ability to improve that I do not like?", and I fix the first thing that comes to mind as soon as possible.

What if it is something that is impossible for you to improve?

Yes, that is where acceptance is required for sure. I found that for me, I was using mindfulness and acceptance as an excuse to avoid dealing with the things I _did_ have the power to control.

It's better for me, my wife, and the world around me for me to manage my sphere of influence and use it to make a space that is comfortable and fun for my family. Learning that I have the power to change some things I don't like is gratifying.

"I found Jesus and meth-amp-hetamines!" (I realize you almost certainly mean adhd medication)

I do worry that practicioners jump too quickly to antidepressents versus attempting other interventions, but I've also seen practitioners fail to have even basic alternatives. To quote one MD, "Oh that sounds bad... uhm, maybe therapy?" No referral, nothing.

We are starting to see Cognitive Behavioral Therapy take flight not just as a guided therapy but also something where the patient can just work through a workbook solo and try exercises on their own.

I see this observation a lot on conversations around positive thinking and CBT too.

When your life actually sucks, no amount of positive thinking is really productive. At some point trying to turn everything into some kind of positive is basically self-abuse.

Using medication to force your brain to stop being unhappy in truly crappy circumstances is more or less the same.

You nicely comment on an important point.

To non-psychiatrists depression is a synonym for sadness.

To a psychiatrist depression is more about the functional impairment (social occupational effects).

How sad you are is only a tiny part of how clinically "depressed" you are!

Check out how depression is graded in research and clinical practice.

* https://www.mdcalc.com/calc/10043/hamilton-depression-rating...

* https://www.mdcalc.com/calc/4058/montgomery-asberg-depressio...

* https://www.mdcalc.com/calc/1725/phq9-patient-health-questio... (sadness isn't even the first question for the PHQ9!)

You could have a wildly effective antidepressants that doesn't make you happy, or you could be crushingly sad and not depressed (subclinical depression).[0]

[0] https://pubmed.ncbi.nlm.nih.gov/18688776/

What if they weren't sad? What if they were depressed, but the cause of their depression was situational rather than a chemical imbalance? Isn't that possible?

Didn't recent research show that's it's usually not a simple case of "chemical imbalance". So, antidepressants on their own won't do much. Maybe getting kicked out of this "unhealthy homeostasis" by medications helps some people find new ways of coping/perceiving their life, but AFAIK that's not the default case. So, they should be administered with therapy (and no, I don't consider therapy seeing them once every two months to renew your subscription lol)

No one in recent history thought it was a chemical imbalance. But there was a recent paper on it yes.

Here's a real mind bender. In social anxiety (at least), people on the same antidepressants will have detectable differences in neurochemicals based on if they were told the pills would work, or won't work.

Mind bender.

https://www.nature.com/articles/s41398-021-01682-3

This is an excellent point. Thanks for the links. I will note that the first says I'm normal even though I sometimes feel like "life is not worth living" and my condition has definitely had a significant negative effect on my productivity. Life-long and probably life-changing.

As an N=1 report, I've been taking the Zembrin supplement (per the Astral Codex guy) for about a year, and it does _seem_ to knock out the sadness component. But this leaves the "unproductive" component, which is sometimes just a small drag, and at other times leaves me almost catatonic. Alcohol mostly fixes that, but has other problems, and I've lately quit.

No specific advice other than to just keep reading and experimenting. And if you're in a bad life situation, try to get out of it.

Hey thanks for that!

I tried to remember what I was like ten years ago and was definitely “severely depressed”, the first link said that. I was constantly agitated and anxious, had insomnia, would call people crying at 3am, and was obsessed with thinking I had some terrible illness all the time.

Despite some mild anxiety the same rubric says I’m normal now, so that’s nice.

The Adderall doesn’t really improve my mood so much as it lets me accomplish the things I need to do in a day, so instead of having a bad feeling in the pit of my stomach like the sword of Damocles over my head, I can relax.

Most interesting to me is how I was completely self absorbed and only had myself to worry about, and now that I have a wife and kids, I was less depressed in the years we didn’t know if our young daughter would make it to adulthood due to illness. My remembered experience is that my mid-20s when I was flunking out of college and playing WoW 60+ hours a week was a way more painful time in my life.

Coming off of Paxil is the worst. I've come off of it, I've read it can even be similar to come off of than heroine. I was sick for weeks with lingering aftereffects that I'm still not completely recovered from (I've read it can take over a year)

> Reality lies somewhere in the middle

HN struggles with this concept in general.

HN is made of people. IT'S PEEEOOOPLLE!!!!

Reality?

The good old "Statistics don't apply to an individual"

Not targeted do you in particular. I generally have a very poor opinion of doctors.

According to the article: "In around 15% of cases, they offer large benefits". If this figure is accurate, then I would somewhat speculate that this figure would drop to less than 5% just by fixing diet alone.

I'm not sure how many doctors would actually suggest a _correct_ dietary change. (the general advises avoid junk food , eat your greens and lots of fiber: while the former is correct the latter two is not, and can even be a disaster)

But I have an anecdotal story about how they affected a single person!

I would broaden this to "conversations about health" in general on HN.

(Does HN support ~strikethrough~? On mobile or I'd try to find the official documentation.)

I don't think so, it's not listed in the docs: https://news.ycombinator.com/formatdoc

so it goes: consciousness emerges from stardust in infinite permutations

one class of mutation becomes homo sapiens and that class can have a bug in the code called depression

other homo sapiens manufacture biology modifiers that fix those other experiments

and that is good?

Depression is a feature not a bug. It’s like saying hunger is a bug.

Don’t forget, they’re a simple way to make your spirit sleep, ask yourself who is it that really didn’t like you enough to suggest you get diagnosed?

It's pretty obvious that antidepressants help people, but I pretty firmly believe they are unnecessary.

Vigorous exercise (morning is better) and time outdoors should be the first thing prescribed to these patients. The former being probably the most important.

I was on and off SSRI's for awhile. Pretty chronically "depressed" through my late teens up to about mid 20's (shocker!). Exercise, talking to someone, and realizing that I am the one who's in control of this has helped me more than any anti-depressant. Similar story with several of my good friends.

The jump to medication in my case was a result of laziness and impatience. Once I got past those two nasty traits, "depression" was a just a bout of sadness that comes when I should feel sad.

As they say, the plural of anecdote is not data, and here we don't even have a plural.

Yes but as a famous man once said, "when the anecdotes and the data disagree, the anecdotes are usually right". Not sure how accurate that is, but it points to the possibility data is being measured incorrectly.

Whether it's factually right or wrong, it's still important to use your intuition and question science and research.

There is something else that points to. Not everything is measurable.

"Just exercise vigorously" isn't actionable advise for many people struggling with depression.

Telling people with a disorder that often goes along with sleep disorder to "just exercise vigorously in the morning", and linking it with "laziness and impatience" is either a misunderstanding of the disease or simply mean.

Change the environment. Consume less inputs. Work towards something meaningful. It is the hardest thing they will ever do but it is what they need to do. I never said it was easy.

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