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I would have loved to have seen this comment of yours at the top of the thread instead; I agree with everything in it. Further, I'll also step forward as someone who also deals regularly with crippling depression; being more open about it is what I've resolved to do after Aaron's suicide, and the suicide in November of one of my clients. (I've written only a very little about it before, http://www.robsheldon.com/blog/depression-programming/)

You're absolutely right that we can be sneaky. A huge part of that is the stigma associated with depression. I'm certain that if all of my clients knew about it, I'd lose some of them for the simple fact that they'd consider me unreliable in the long term.

So, when Taren mentioned that she'd been "reading up" on depression, and concluded that that wasn't what Aaron was suffering from, I did cringe a little. I came to the comments here expecting to find some discussion of depression; what I didn't expect was the top comment completely dismissing Aaron's suicide as being only about depression.

Depression is probably different for different people, like most things. Mine simply makes me more susceptible to struggling when life gets hard. I'm rarely depressed when the sun is shining and there's money in the bank account and my car is working and my business is good and my friends and family are happy. When too many of those things are off, I feel it intensely and my default biochemical response is to crawl into a hole and want to disappear. I have to fight my way back out of that, every time.

So I find Aaron's case very easy to empathize with. If I were in his situation -- inasmuch as I understand his situation at this point -- I'm honestly not sure what I would do. I can tell you that I'd feel overpowered, hopeless, and defeated. I can also tell you that I would want to punch anyone in the face who said that if I chose to commit suicide as a result of the situation, it would be primarily because of my depression.

I went through a period of depression two years back. My family and friends were the last people to notice it. I put on a strong face for them and went out of my way not to worry them. The people who did notice were professors and classmates, people who I didn't make much of an effort to "impress". When those close to me started to realize they all began to rationalize it as being the result of drugs or sleep loss or a recent break up. You just aren't the type of person to be depressed they said, it's not like you. Sad as it may be, they knew even less about how I was than random strangers on the bus. I suspect a lot of it had to do with how they viewed depression and the stigma surrounding it.

Do you know how psychiatrists or clinical psychologists diagnose depression? Have you read the DSM? Do you know how they come up with the criteria for psychiatric disorders in DSM? Do you know the controversies behind DSM? Do you know few decades ago homosexuality was regarded as a mental disorder? Do you know that there are researchers who want to introduce a new "psychiatric disorder" (i.e., hypersexual disorder) in the next edition of DSM for people who have sex more than 7 times a week ?

Here is the criteria for major depression: Diagnostic criteria:

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day

1. Depressed mood most of the day.

2. Diminished interest or pleasure in all or most activities.

3. Significant unintentional weight loss or gain.

4. Insomnia or sleeping too much.

5. Agitation or psychomotor retardation noticed by others.

6. Fatigue or loss of energy.

7. Feelings of worthlessness or excessive guilt.

8. Diminished ability to think or concentrate, or indecisiveness.

9. Recurrent thoughts of death (APA, 2000, p. 356).

I am sure everyone has met some of its criteria at some point in their life. Without a real diagnosis, you really can't say if the person has a major depression. Even with a diagnosis, how do you know the doctor is making the right diagnosis with SUCH VAGUE criteria?

Edit: I am very aware of what DanBC has pointed out about the other criteria: i) at least 2 weeks ii) and at least five of the following symptoms iii) clinically significant impairment in social, work, or other important areas of functioning almost every day.

BUT THEN, the question becomes "Why 2 week?" "Why at least five of the symptoms?" Who came up with the numbers? Let me tell you, the DSM committee have a lot of disagreement about those. Those numbers are not some magic numbers that once you pass that threshold, you suddenly become clinical depressed.

> Do you know how psychiatrists or clinical psychologists diagnose depression?

Yes, and do you know how much variability exists between practitioners? Diagnosis is largely a matter of personal opinion, not science.

The reason for that, in turn, is because no on knows what causes depression -- it's not like a medical condition with an identified pathogen and clinically validated treatment.

But the vague state of depression as an illness with an unknown cause doesn't prevent psychiatry and clinical psychology from offering therapy and drugs of dubious efficacy.

Antidepression drugs have been shown to be ineffective in most cases --

Link: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fj...

Title: "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration"

Quote: "Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance."

The story is that drug companies publish only studies that support their belief in their drugs' efficacy. But when completed but unpublished studies are included, the evidence for the efficacy of antidepression drugs evaporates.

The study's authors don't say the drug companies deliberately suppressed negative findings -- they leave that conclusion to the reader.

I have many bad things to say about many antidepressant. E.g., they all have very annoying side effects, at least for me, and some of the side-effects (e.g., vivid dreams) require benzos to counter. And then benzo addiction is really no fun at all.

Other side effects I experienced were clearly under-reported by the pharmaceutical companies. E.g., negative sexual side effects for Prozac that my doctor wouldn't even believe were real and not psychosomatic, until it later turned out that 25%-50% of all patients suffered these side effects, and the pharmaceutical company had neglected to inform anyone.

On other other hand, Remeron surely saved my life. I have no doubt about this. I had been in the most miserable state you could ever possibly imagine and then some, and had been this way for months, and then within a day or two of starting Remeron, I was utterly fine. (Though ironically, it may have been another antidepressant that put me in this terrible state to begin with, as I had to go off it cold turkey due to it causing a different dangerous side effect.)

As for diagnosing depression, it may certainly be the case that many cases are difficult to diagnose correctly. And there may be cases where there is no fact of the matter as to whether the particular symptoms count as depression. On the other hand, there are certainly cases where there is no question at all as to whether it's depression. I have been there quite a few times, and it's been as cut and dried as anything can be in this world.

> On the other hand, there are certainly cases where there is no question at all as to whether it's depression.

Yes, absolutely, but saying "it was depression" is not the same as saying "depression is a disease with a proximate cause that can be identified, diagnosed and treated."

The present debate surrounding depression is global in scope. No one knows whether depression is a disease in the way that a cold is a disease, or is an extreme case of normal emotion, not amenable to any kind of diagnosis or treatment.

None of this is meant to argue that depression isn't a disease in the way that a cold is a disease -- only to say there's no reliable science behind the claims.

But we do know this -- in controlled scientific studies, antidepression drugs don't actually work for the majority of patients:

Link: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fj...

Title: "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration"

Quote: "Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance." [Emphasis added]

Comment: Drug companies have been only publishing studies that supported their drugs, and discarding those that didn't. This study compares the outcomes for all the studies, published and unpublished, and the result is that antidepression drugs do not work for the majority of patients.

>the result is that antidepression drugs do not work for the majority of patients.

I suspect that this is because most patients don't have the patience or wherewithal to try enough different kinds, or a doctor who is willing to combine them with benzos. The patient's patience is especially relevant since when you are depressed, the last thing in the world that you need is to add extra suffering from side-effects to your list of woes. Or at least that has been my personal experience. After a few bad experiences, I was very reluctant to try additional antidepressants, and after having become dependent on Ativan once, I vowed to never allow that to happen again either.

Ultimately though, I tried just about every modern antidepressant before finding one that worked, and I know people who had to go to tricyclics, which has caused them to become fat, but happy. Each of the antidepressants I tried affected me differently. But at this point, I am very relieved to know that if I become depressed again, there is a drug that I know for sure works for me. Knowing that is a huge weight off of my shoulders. Though having to look forward to weaning off of benzos again puts some of that weight back.

More recently I tried ketamine when I was worried that I was going to become depressed due to an unfortunate life circumstance. I'm here to say that it apparently worked as well as hyped since I never became at all depressed during a situation that would typically have sent me into a downward spiral. And with no ill side effects too boot. Too bad it's not legal....

Of course, trying many different antidepressants is not without its risks, as I alluded to previously.

> I suspect that this is because most patients don't have the patience or wherewithal to try enough different kinds, or a doctor who is willing to combine them with benzos.

No, no, we're talking about controlled studies overseen by scientists, not psychologists or psychiatrists in ordinary clinical practice. Typically, such a study has an experimental and control group. The experimental group gets the drug under test and the control group gets a placebo. To minimize the possibility of bias, during the study neither the experimenters nor the subjects know which subjects are controls.

After the study, the histories of the subjects are compared, and the groups to which they belong are finally revealed. Every precaution is taken to limit bias and emotional attachments to any outcome.

As it turns out, when such studies are conducted and compared to other similarly disciplined studies, the efficacy of antidepressants evaporates. In plain English, they do not work.

That's the scientific finding. It's not an opinion, like much of psychology, it is a scientific result.

> But at this point, I am very relieved to know that if I become depressed again, there is a drug that I know for sure works for me.

Yes -- and so does astrology, but only if you sincerely believe it does.

The fact that Remeron worked for me has absolutely nothing to do with belief or placebo affect. In fact, I was absolutely certain at the time that Remeron would not work, due to my previous bad experiences with antidepressants and my terribly negative state of mind. Also, there is absolutely no scientific evidence that the placebo affect can have such a drastic and lasting effect. I was not just a little blue; I was out of my mind @#%$ing batshit crazy. For months and months, and then a few days later, completely cured. A cure that has lasted for years.

As to your claim that "they do not work", the scientific evidence that they work may be questionable, but lack of scientific proof is not the same thing as scientific disproof. You have no proof that they do not work for many people, despite your claim, as the way the drugs are used in double-blind studies do not perfectly mirror their use in the actual world. E.g., combination with other drugs, such a benzos, and/or other antidpressants, and trials of a number of different drugs to find which one is best of that particular person's brain chemistry.

Furthermore, one doesn't need scientific evidence to know certain things. I don't need published double-blind scientific evidence to know that if I hit my toe with a hammer that it will hurt. I don't need scientific evidence to know that my wife loves me.

Another point of evidence: Paxil also cured my depression within a day or two, on a different occasion, but it also had many other effects on me that were highly undesirable. It removed all pleasurable sexual sensations. It made me hypomanic and not care about how I treated other people. I felt as if everyone else in the world was an asshole who didn't give a shit about me, and so I was free not to give a shit about them. I felt absolutely no affinity any more for the people that I loved. I only found them annoying. I.e., my normal personality was turned completely upside down.

I don't need scientific evidence to know that this is how Paxil effected me, any more than I need scientific evidence to tell me how alcohol or marijuana make me feel. These are not subtle things, and the effect of Paxil on me, and the affect of Remeron on me were anything but subtle. They were as psychoactive as any substance can be.

Now since my evidence is not scientific, I am not stating that you should be convinced. On the other hand, you have no grounds to assert that I was cured by the placebo effect. You don't know me and you don't have access to the personal experiential information I have. I, personally, have plenty of information to make an accurate and rational conclusion here. And I have.

> The fact that Remeron worked for me has absolutely nothing to do with belief or placebo affect.

With all respect, you cannot make this claim. The only way this claim could become scientific would be with a double-blind scientific study. Such a study would compare the drug with ... a placebo.

And, as I have pointed out, the studies that have been conducted do not support the claim that antidepressants work for the majority of people -- indeed, studies demonstrate the opposite conclusion, that they do not work.

> On the other hand, you have no grounds to assert that I was cured by the placebo effect.

Yes, which means it's a good thing that I never said that anywhere. And why would I? The claim makes no sense -- no one is ever "cured" by the placebo effect.

> I don't need scientific evidence to know that this is how Paxil effected me ...

Wow. The drug companies must love clients like you.

> I, personally, have plenty of information to make an accurate and rational conclusion here.

You are ignoring the readily available scientific findings, so no, your conclusion is neither accurate nor rational.

This is an excellent capsule summary of modern psychological research -- no electron micrographs, no useful in vitro results, no objective evidence. No known causes for diagnosed conditions, and subjective diagnostic criteria. Instead, a nearly complete reliance on the self-reporting of clients, who insist that the drugs do or do not work, or the therapy works or doesn't work.

No matter how sincerely psychologists and psychiatrists want to help people, this charade will continue until real science begins to be done, and for that, we'll probably have to completely switch away from psychology to neuroscience. As it happens, Thomas R. Insel, the sitting director of the NIMH, agrees with this view:

Link: http://www.scientificamerican.com/article.cfm?id=faulty-circ...

Quote: "In most areas of medicine, doctors have historically tried to glean something about the underlying cause of a patient's illness before figuring out a treatment that addresses the source of the problem. When it came to mental or behavioral disorders in the past, however, no physical cause was detectable so the problem was long assumed by doctors to be solely "mental," and psychological therapies followed suit. Today scientific approaches based on modern biology, neuroscience and genomics are replacing nearly a century of purely psychological theories, yielding new approaches to the treatment of mental illnesses."

> And, as I have pointed out, the studies that have been conducted do not support the claim that antidepressants work for the majority of people -- indeed, studies demonstrate the opposite conclusion, that they do not work.

Furthermore, you are misrepresenting the strength of the scientific data that supports your claims: (1) The meta-analysis did show clinical significance in severely depressed patients. (2) The meta-analysis only looked at SSRI's. Remeron is not an SSRI. And most of the people that I know who are satisfied with their antidepressants are not taking SSRI's. (3) This is a single study. Individual studies are often contradicted by further studies.

From my experience with side-effects, I would not recommend anti-depressants for anyone who was not suffering from a major depression anyway. The risk is not worth the reward for just being down in the dumps. For mild cases of depression, it's not even clear to me that accurate diagnosis is possible. How can doctors accurately differentiate between mild depression and just being sad due to unfortunate life circumstances? Until we can do brain scans or blood tests to identify depression, I don't see how they could. And without the ability to make accurate diagnoses for mild cases, it's not clear to me that the data on drug effectiveness for mild cases can mean much anyway.

> With all respect, you cannot make this claim.

With all respect, I most certainly can. I know myself well enough to know how I respond to drugs. I'm sorry if that is not the case for you. I also know that I don't suddenly pop from the depths of the worst despair imaginable to being completely normal in a day or two on a hope and a dream. If that were the case, many other things would have cured me. Such as the dozen or two medications I tried before Remeron, for instance.

> The only way this claim could become scientific would be with a double-blind scientific study. Such a study would compare the drug with ... a placebo

I specifically stated that my claim was not scientific. All knowledge does not come via science. As I already mentioned, I cannot prove scientifically that my wife loves me, and yet I know this to be true. You may have no good reason to believe me about that, but that has no bearing on what I know to be true.

> Yes, which means it's a good thing that I never said that anywhere. And why would I? The claim makes no sense -- no one is ever "cured" by the placebo effect.

The placebo affect is real, so it can certainly act as a cure for minor ailments of certain sorts. I have no desire to argue semantics with you. On the other hand, it was Remeron that cured me, and I'm as sure of that as I am that I am not conversing right now with an AI program, though I can't prove that scientifically, either.

As I also mentioned, you do have not have any particularly good reason to believe me, but for reasons I have stated, you also have no good reason not to believe me. If you were not an ideologue, you would remain agnostic.

> Wow. The drug companies must love clients like you.

Your assertion is that a drug company would love me because I am willing to testify to the fact that Paxil made me hypomanic and I would assert to anyone that it is a dangerous drug and I would advise them to stay away from it if my experience is at all representative? You have a strange notion of what drug companies might love.

I've been told by doctors that I had a phobia of antidepressants because I was so utterly resistant to trying anymore after my terrible experiences with them. You sound like them: The hypomania was all in my head. The sexual dysfunction from Prozac was all in my head! Welcome to the club of quack shrinks!

> You are ignoring the readily available scientific findings, so no, your conclusion is neither accurate nor rational.

I am ignoring nothing. If you actually read what I wrote, you would know that.

As to your claims that neuroscience research will likely be hugely beneficial to our understanding. Well, of course. That verges on tautology.

>> With all respect, you cannot make this claim.

> With all respect, I most certainly can.

I recommend a refresher course in science.

> I recommend a refresher course in science.

I recommend that you learn to read. And how to not be a jerk.

I think you misunderstood me a bit. I asked that question to suggest exactly what you have said. The way they diagnose people with all the vague criteria is not scientific at all. I completely agree with you. And yes, I am also aware of the variability among practitioners.

I should have read your post more carefully before assuming there was any significant division between our views.

For what it's worth, I kinda agree with what I think you're getting at -- that the diagnosis for depression needs a lot of work and the DSM isn't infallible -- but your comment here is easy to interpret as a skepticism of the existence of depression, which might be why it's getting downvoted.

Fortunately, there have been some recent advancements in neuroscience that can give us hope for improved diagnosis in the future (once the field is able to agree on what depression is, anyway).

> I am sure everyone has met some of its criteria at some point in their life

It is incredibly frustrating that you say this, even while quoting the DSM which says:

i) at least 2 weeks

ii) and at least five of the following symptoms

iii) clinically significant impairment in social, work, or other important areas of functioning almost every day.

These symptoms are not vague. Unless you take one symptom, and ignore the significant impairment clause.

> These symptoms are not vague.

Of course they are. And there's a lot of variability in diagnosis between practitioners. Some even say that depression isn't really a disease at all.

There is an excellent book on this topic that I cannot recommend highly enough:

Title: "Manufacturing Depression: The Secret History of a Modern Disease"

Link: http://books.google.com/books?id=U-lvlVSGeEEC

Quote: (about Congitive-behavioral therapy) “a method of indoctrination into the pieties of American optimism, an ideology as much as a medical treatment.”

Here's a discussion of the book (and topic) at the New Yorker entitled "Head Case": http://www.newyorker.com/arts/critics/atlarge/2010/03/01/100...

I've always felt depression is only somewhat understood, as you say it's hard to diagnose.

For example, #7 is a common one for me - and you simply can't see it or diagnose it unless I tell you. But you can usually tell from other things; like the fact I get obsessed with ideas and spend a lot of time walking (i.e. thinking/brooding).

I agree with you; and I wasn't exactly trying to make a diagnosis over the internet. I was trying to point out that although Taren seems so certain he was not depressed, she makes some claims which are very much not the be-all-and-end-all of depression. And that some of the activities she describes are common tells for depression.

My point being; it's not simple, and depression is a complex and evil thing.

Thanks for these thoughts. It makes me wonder about Jody Sherman. I didn't know the man, yet every thing I've read about him sounds like he would be amazing to be around--and a great friend. He, maybe more so than Aaron, had even more to look forward to (i.e. no federal lawsuit, etc). And yet, Jody chose the same end. So sad.