The Other Side of Depression
annewheaton.com
annewheaton.com
The only problem with this is that it's essentially a PR line that both doctors and the general public have mistaken for science. We don't know all that many facts about how brain chemicals work with regard to mood disorders. We have empirical results from clinical trials and broad use of antidepressant and antipsychotic medications, but there is no basis to believe that medications "balancing out those chemicals" serve to repair mood disorders.
If the medications helped, then great, I know they have helped a great number of people, but they also fail to help a great number more and these success stories have an unfortunate tendency to marginalize people that do not get good results from medication. It often results in victim-blaming, to make sufferers of depression wrong for stopping their medications for legitimate reasons (let's face it, all of these results are highly subjective), and for overstating the ability of our current medications to cure all mental ills.
That sound derogatory.
Did you expect her to go into detail about serotonin, what the latest Science tells us it does, what serotonin uptake inhibitors do, etc?
The woman wrote an article that is really just an ice breaker on how she and her partner dealt with acknowledging that there was a depression problem and getting help for it. She felt that her contribution to the problem of depression was to relay a little of Wil Wheaton's story from her perspective.
but they also fail to help a great number more
No one has said that every case is the same. In fact, TFA specifically mentions that fact as well as anecdotally telling us about how Wil had to change his dosage and medication to meet his specific and dynamic neurological profile.
That "sticks shaped these ways" happen to affect neurotransmitter levels is a great guide to finding others, especially the great moves in safety from MAO inhibitors -> trycyclics and the like -> 3rd generation started with Prozac, is sort of besides the point. That they make a really significant difference for lots of people is.
Not that wikipedia is the last word, but, "[...] companies such as Pfizer continue to promote drugs like Zoloft with advertisements asserting that mental illness may be due to chemical imbalances in the brain, and that their drugs work to "correct" this imbalance. Most academics believe that the advertisements are oversimplified and don't fully explain what is happening."
Oversimplifications
I was simply pointing you to a reference that showed that "academics" use the exact same language regarding chemical balance of neurotransmitters as the original author.
Notice that it didn't say, "Academics disregard the chemical balance explanation because it lacks evidentiary support."
>Notice that it didn't say, "Academics disregard the chemical balance explanation because it lacks evidentiary support."
A lack of explicit critique in a rephrasing on wikipedia should not be used as evidence.
The cited article for that sentence (http://www.medscape.com/viewarticle/516262) is from 2005 and includes the following:
> Numerous studies to identify reproducible changes in neurotransmitter levels in the cerebrospinal fluid of clinically depressed patients, or to induce or correct depression by manipulating brain serotonin levels, were inconclusive and fraught with methodological limitations.
> Gordon McCarter, PhD, an assistant professor of biological sciences at the College of Pharmacy of Touro University in Vallejo, California, agreed that the evidence for an "imbalance" in neurotransmitters causing depression is "circumstantial" and "more and more tenuous." He noted the dearth of studies showing any measurable difference in serotonin or norepinephrine between depressed patients and controls
> "The Diagnostic and Statistical Manual of Mental Disorders does not list serotonin as a cause of any mental disorder; it is simply one neurotransmitter that continues to be investigated. And the prescribing information for the SSRIs does not claim that their mechanism of action is to correct a chemical imbalance, although this is exactly what the advertisements claim."
> "We suspect that many consumers believe the serotonin theory to be more scientifically based than it is, and that they might have chosen an alternative approach to their distress if they were fully informed.
Ronald Pies, MD, psychiatry professor at SUNY Upstate Medical University and Tufts University School of Medicine, and editor of the Psychiatric Times.
http://www.psychiatrictimes.com/blogs/couch-crisis/psychiatr...
SSRIs increase levels of serotonin at the synapse when administered by preventing serotonin re-uptake and recycling, improving mood.
SSREs decrease levels of serotonin at the synapse when administered by enhancing serotonin re uptake and recycling, improving mood.
Two drugs with opposite effects achieve the same qualitative result, even though it can't be said that they produce similar quantitative results. Thus, vastly different quantitative profiles are correlated with the same qualitative results; X + 1 = X - 1.
On top of that, there's no way to even measure levels of synaptic neurotransmitters in vivo.
That said, too much or too little serotonin absorbed by a specific set or another can have wildly different effects.
Too much serotonin is not a good thing. So you need to balance it. For some people, this means SSRIs, for some it means SSREs. That's the explanation for the imbalance model, and it does make sense given the science.
Sure, blast a brain with drugs that aren't well understood and it'll behave differently, maybe "better" than before, relatively speaking-- but that's not a scientific model so much as a pragmatic clinical solution.
Sure, dump in a bunch of spices that aren't measured and it'll taste different, maybe "better" than before, relatively speaking--but that's not a scientific model so much as a pragmatic cooking solution.
SSRIs bind to the serotonin transporter SERT. The 'selective' part means that it has a much higher affinity for SERT than other monoamine transporters (e.g., DAT or NET). Although you're correct that there are various serotonin receptor subtypes, there is only one known SERT (there is only one gene).
SSRIs do exhibit extremely weak affinity to serotonin receptors but it is so low that it doesn't matter which subtype has a higher affinity than another. If you want to latch on to 5HT receptors with interesting ratios and affinities, the correct psychiatric drug would be an antipsychotic.
Please stop defending the chemical imbalance model when you do not understand the science at all. Thank you.
I self medicate with marijuana. And more than just using it to make me happy, smart, excited and hungry. I grow pot medicinally as well and that makes me feel really happy. There is loads of scientific evidence that points to having a garden and lessening depression. From my experience, I can say that growing marijuana really lends itself to a lot of the benefits of having a garden. Because you can harvest 5 to 6 times/year it makes it something you need to work on every day. Progress is relatively fast, and if you do a good job, you can take it to a shop and get enough spending cash for that new macbook apple just announced. And if you are a champion, you can find your nugs in magazines. (my ghost og kush is featured in culture this month...) But ultimately nothing feels better than smoking my own herbs on Friday night after a long week of gardening and programming.
Just throwing it out there as another alternative for someone that is struggling. Been there, you just gotta find the light.
I don't want to belittle you're experience, because losing a friend to suicide is always brutal, but I do feel that its important to look at reports of anti-depressants causing suicide with a critical eye.
Almost all ant-depressants carry a warning that they can cause suicide, but there are a couple of factors in that:
1. Almost by definition, people who are prescribed anti-depressants are more likely to commit suicide in the first place.
2. I can't find the source on this one, but I've certainly been told by psychiatrists that the first few weeks after going on anti-depressants carries a higher risk of suicide than before going on them. The theory is that during those first few weeks you've been given enough of a kick by the drugs to provide a bit of motivation, but you've not yet had the chance to address the actual cause of the problem. That combination can result in having just enough motivation to carry out your desire to kill yourself.
Unfortunately you'll often see doctors prescribing medication without then following it up with the necessary therapy to help their patient move on from whatever got them into the situation got them to this point to begin with.
Have we ever had a testimonial from a failed suicide in these circumstances? In my case, as my depression and anxiety issues started going away, I suddenly realized how much of a complete weirdo others must see me as and felt shame comparing myself to others in my peer group who, without depression holding them back, have become much more successful. It was a brutal eye-opener for me. I guess when I was depressed I really didn't consider these things or they simply didn't bother me.
It really brought up a feeling of hopelessness, like I wasted my youth and thus will never catch up, or will always been seen as defective in some way. I guess it doesn't bother me much anymore, but given sudden clarity like that can be intimidating. I imagine if someone is already suicidal, it can be a tipping point.
Preach it brother! I feel the same damned way.
> I guess when I was depressed I really didn't consider these things or they simply didn't bother me.
I revel in my weirdness when my mood is different from others-- they're just polyannas. Makes it harder to make that appt. to get the meds adjusted.
You can be depressed and think that you want to die, or that everyone else would be better off if you were dead, or that being dead would be preferable to stewing misery...but feel too apathetic to do anything about it. With or without drugs, you can be in a more active mode where you feel like doing something about your problems, but still feel miserable or be acutely conscious of the pit of misery that you just left, eg if you're bipolar and having a manic episode. So the drug or mood swing might correlate with the impetus to commit suicide, eg getting up and going somewhere to do so or making use of tools to that end. But is the 'suicidal thought' the desire to stop living, or the practical action upon that desire? As someone with some first-hand experience in this area, focusing on the latter seems like blaming the period for the ending of a sentence, while avoiding engagement with the semantic content thereof.
I'm not saying that drugs or other factors can't induce the idea by any means, but most discussions of this issue seem to involve a heft does of post hoc ergo propter hoc, ie the correlation = causation fallacy.
Depression covers a broad range of behaviours and severities.
But to say "anti depressants can cause odd thinking in some people during the first few weeks of use, and people starting anti depressants should be closely monitored" is not controversial. You mention bipolar - it is important to be very careful with SSRIs and people with (possibly undiagnosed) bipolar.
http://www.mhra.gov.uk/ConferencesLearningCentre/LearningCen...
One basic example: I've heard some with anxiety say it calms them down. I've heard others say it makes them freak out.
Carl Hart's book "High Price" had some interesting anecdotes about how drugs interact with underlying brain chemistry, environment, and cultural expectations to give different experiences.
I believe I've also met a bipolar person who had a psychotic episode from pot, though the dude apparently was doing an insane amount; claimed to be having THC flashbacks, which I'd never heard of.
I do do a lot of other stuff (meditation, CBT, ...) and life is pretty good these days.
1) It's inebriating, so you shouldn't drive or operate heavy machinery after using marijuana. It's definitely possible to control your dosages a bit using a vaporizer or pipe, but it takes a fair bit of experimentation to determine your tolerance level.
2) It's short-acting. Whereas the contemporary antidepressants affect baseline mood over a period of time, the mood-enhancing effects of marijuana will largely wear off after 3-6 hours.
3) It's illegal to grow in the US without a license and has varying legality regarding consumption, buying, and selling throughout the world. This might not matter for some people, but it should be a strong consideration for people with families or people who work in environments with routine drug testing. As a child of a parent who used to grow marijuana illegally, it stressed me out as a kid learning to be anti-drug in school yet dealing with the drug-using and growing parents every day.That said, we're still understanding how the brain works. One recent study showed that depression often has an associated and underlying, undiagnosed, sleep disorder [1]. Treat the depression without treating the sleep disorder and the depression comes back. FYI: This work has not been published yet.
Given that scientists have just figured out that sleep clears the brain of toxins [2], similar to the lymphatic system clearing the rest of the body of waste, these results shouldn't be surprising. We don't know the exactly reasons why people get depressed, but the evidence is clear. Depression has a root physical cause just like any other illness.
[1] http://www.nytimes.com/2013/11/19/health/treating-insomnia-t...
[2] http://news.sciencemag.org/brain-behavior/2013/10/sleep-ulti...
As my last keystrokes about depression here on Hacker News pointed out, there isn't just one disease known as depression. Depression is a symptom pattern (prolonged low mood contrary to the patient's current life experience) found often in the broad category of illnesses known as mood disorders. Behavior genetic studies of whole family lineages, genome-wide association studies, and drug intervention studies have all shown that there are a variety of biological or psychological causes for mood disorders, and not all mood disorders are the same as all other mood disorders. I know a LOT of people of various ages who have these problems, so I have been prompted for more than two decades to dig into the serious medical literature[1] on this topic. (I am not a doctor, but I've discussed mood disorders with plenty of doctors and patients.) I've seen people who tried to self-medicate with street drugs end up with psychotic symptoms and prolonged unemployment, and I've seen people with standard medical treatment supervised by physicians thrive and enjoy well off family life. The best current treatment for depression is medically supervised medication combined with professionally administered talk therapy.[2]
The human mood system can go awry both by mood being too elevated (hypomania or mania) and by it being too low (depression), with depression being the more common symptom pattern. But plenty of people have bipolar mood disorders, with various mood patterns over time, and bipolar mood disorders are tricky to treat, because some treatments that lift mood simply move patients from depression into mania. And depression doesn't always look like being inactive, down, and blue, but sometimes looks like being very irritable (this is the classic sign of depression in teenage boys--extreme irritability--and often in adults too). Physicians use patient mood-self-rating scales (which have been carefully validated over the years for monitoring treatment)[3] as a reality check on their clinical impression of how patients are doing.
As the blog post kindly submitted here points out, a patient's mood disorder influences the patient's whole family. The more other family members know about depression, the better. Encouraging words (NO, not just "cheer up") are important to help the patient reframe thought patterns and aid professional cognitive talk therapy. Care in sleep schedules and eating and exercise patterns is also important. People can become much more healthy than they ever imagined possible even after years of untreated mood disorders, but it is often a whole-family effort that brings about the best results.
[1] http://www.amazon.com/Manic-Depressive-Illness-Disorders-Rec...
[2] Combination psychotherapy and antidepressant medication treatment for depression: for whom, when, and how. Craighead WE1, Dunlop BW.
Annu Rev Psychol. 2014;65:267-300. doi: 10.1146/annurev.psych.121208.131653. Epub 2013 Sep 13.
Take care.
Not every mental illness is a chemical imbalance, it might be neurological in nature, or it could be stress based, or maybe you just need a psychotherapist and learn some coping skills?
I think they are developing new neuroscience theories on the brain so they can fix what is wrong with psychiatry. I would recommend this book: http://www.amazon.com/The-Future-Mind-Scientific-Understand/...
It seems to discuss the basics of neuroscience and how the brain and mind work. It also discusses medicine and how to fix things. It might be a good read for you.
> Encouraging words (NO, not just "cheer up")
Would you mind sharing a little on how to go about this exactly? To be clear, I'm not surprised that "cheer up" isn't the right way - but I don't know what is. I don't even know how to talk positively to, say, cancer patients, let alone sufferers of mood disorders.
Chronic depression is a bit like an old AM radio; you can mitigate the lousy signal with the tuning knob and moving the antenna around, but you can't fix it and call it done; the station that's clearly tuned in today might stay clear tomorrow or be mired in static. As a patient, one can learn to separate oneself from one's mood, so that feeling miserable doesn't have to be attributed to an objective exterior cause. But learning that takes time, and inability to distinguish between one's emotional and the quality of one's environment was a major problem for me when I was younger.
The most helpful thing you can do is be around to listen and allow the depressed person to vent without pushing them to identify an actionable solution, frustrating as that may be. Asking questions can also be helpful, to inform yourself about what the other person is experiencing. For example suppose you were talking to a blind person; you get the basic idea of being blind but you don't know what it's like, so it's quite reasonable to wonder, say, how the person chooses groceries or decides what clothes to put on in the morning. When depression is chronic one develops a variety of coping strategies (which work more or less well at different times), and articulating that sort of thing often helps me get out of a trough and recover my sense of agency.
One other thing that's very common for people with depression is muscle pain, because the inner tension is often mirrored by a physical tension. It's hard to describe, but the physical tension can even act as a focus for the bad feeling. A backrub or a neck rub can go a long way, if the depressed person is feeling up to it. Other times one may not want to be touched and is better off just going to bed or somesuch.
Unless you're a close friend (with whom the patient is completely at ease), then you're putting them in a position where they feel like they have to act strong, smile, and thank you for your concern. (For my situation, I got dozens of phone calls from people I hadn't heard from much in years. I had more than enough on my mind than to appease their desire to show their concern.)
Your concern is definitely appreciated, but you need to choose your moments.
As for what to say? I guess that differs culturally and your relationship. I'm Australian, and I was totally okay with a simple "ah, shit mate, that sucks" over a "if you need ANYTHING, call me* (*but don't actually call me)" - I know I can call for help, and dozens of people can help, but all I really wanted was to be treated like a normal human. For instance, I was bald from the chemo and got a multi-colour clown wig as a joke present, which made me smile so much. It was a sense of "everything is normal despite being in the midst of chaos." I could count on my friends to distract me from the horrible reality of the situation when I was stressed/sad/confused.
And that is your job. Be a sincere option for distraction and advice when you're called upon. Trust them to ask for help when they need it..and they're much more likely to ask for it if they know you won't be overbearing/over-worried/judgemental/etc.
I don't know how well this advice applies to depression, but I think it's a good framework for being a good friend through most hardship.
(Sidebar: I'm more than happy to be a sounding board for approaching any cancer related issues you've got. Email's in my profile. I've heard all kinds of things, so don't think any question or issue is too simple or stupid!)
You did mention cognitive talk therapy with a professional, but my reading of David Burns' books (and my subsequent personal experience) leads me to believe that it can be effective when done by someone by themselves (and in combination with medicine and or talk therapy).
http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
(Granted, I don't know about the "behavioral" addition to cognitive therapy, but the latter is on a sound footing in every way, from theory to practice, and I can personally attest to it being effective.)
http://www.psychiatrictimes.com/cognitive-behavioral-therapy...
Mindfulness also has good evidence, but tends to be used with more severe forms of depression or other diagnoses such as borderline personality disorder.
The comment "sounds like voodoo to me" is unconstructive. I don't care what something sounds like to you. If you had said why it sounds like voodoo, why you have a problem with any of the research that supports it or the Cochrane reviews or the NICE guidance then there's something to talk about.
No double blind studies. "The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in."
"This study concluded that CBT is no better than non-specific control interventions", which I already guessed at in my previous comment.
"Taken together, trials using psychotherapy do not meet the qualifications of high quality evidence."
However, like Wil, I seem to be getting angry at the most trivial things. I am considering starting again, but I am about to graduate and take my last finals in a week or two.
I have been scared of taking medication because of what ADHD meds did to me in my youth. Though now, knowing everybody on my mothers side and my sisters needed help for depression at some time or another, I highly support getting help in this domain.
If you can't afford to do so privately, and you're in the UK, the advice below should help you navigate the NHS bureaucracy and (eventually) see a therapist.
Start with your doctor, GP will probably attempt to put you on anti-depressants immediately and then leave it at that. If that's not what your looking for, refuse, and ask for a referral to a specialist. If that doesn't work, ask to see a different GP. Eventually you should get referred to an actual psychiatrist. They're also going to want to stick you straight on medication, but you'll at least get an appointment with them now and again to discuss that, but they can refer you to a therapist.
As you may be able to tell from my tone, over the years I've have acquired very little respect for the way the NHS treats mental health. There are a few individuals doing fantastic work, but they've always been hamstrung by the bureaucracy involved in making anything happen.
In the US, if you're in college, go to your student health center. They have people who are very experienced with helping students with their issues.
If you're not, check your employers health offerings. Mine has an anonymous number that we can call, separate from HR and management, to get help and referrals. They even paid for the first 5 (6?) sessions before I went to my own insurance.
If your office doesn't have that, or you're not comfortable going through them, go to your regular doctor for a referral.
If you've got friends that you know have dealt with these issues in the past, ask them for a recommendation. You don't have to be specific, you don't even have to tell them you're depressed (or think you may be), just say you need someone to talk to and ask who they went to.
Don't be afraid of not being depressed enough. I made the mistake of doing that and got to a really bad place before I finally sought help. It's also worth noting that, by the time you actually get in to see a doctor, get prescribed something, and then wait the required time period for the medicine to actually start working, you'll be about 2-3 months out from feeling better.
When seeking depression treatment, another thing that was kind of obvious in hindsight (but not so much at the time) is that no one is going to magically come and save you from depression, not even your loved ones. You have to take the initiative to seek help yourself. For months I stalled because I didn't want to go through the process of finding a doctor, and it really ended up biting me in the ass.
Good luck!
I'd add that I'll bet anyone can benefit from going through their thought patterns applying the insights of congnitive psychology, the therapy side of which says, very roughly, one way to make yourself depressed is to think incorrect bad thoughts about yourself (which includes how you view other people viewing you, etc.).
(Which is not to say there aren't also pure biological causes (see tokenadult's excellent comment: https://news.ycombinator.com/item?id=7530847), family history eventually revealed that's a factor in my particular type of depression, but it's certain that self-applied cognitive therapy from an earlier edition of this book made a big difference for me, it's just not enough.)
Therapists don't prescribe medication- the best they can do is refer you to a doctor or psychiatrist. They can often answer questions about medication though, and help you decide whether that path is right for you. Therapy isn't about medication, it's a different tool altogether.
I've found that this is one of the big reasons that many people I know don't seek help, or waited (too) long to do so. Especially for people living alone who can acceptably 'curate' their existence when around others, it's very easy to lose perspective on what is 'normal' or 'healthy'.
It's made me wonder if it might be good to consider going to a psychologist something akin to a yearly dentist checkup.
I know that the "chemical imbalance" explanation is a poor excuse for "we don't know exactly how it works". But there are so many progresses done in our quality of living that were done because someone had a hunch and some practical, reproducible results showing that it worked. Think about the practice of washing hands when going from one patient to another in a hospital? When it was suggested, people couldn't see a connection with dirty hands and spreading diseases.
I lost a son that suffered from a mood disorder to suicide. It is heartbreaking and it happened when he was apparently getting over the hump of his darkest moments... I have other two children that also struggled with depression and what I found that worked the best for us so far is communication. Being opened about our struggles, talk therapy in conjunction with medication.
I tried to write about mental illnesses and the startup community, which I think is something that needs to be talked about. But my submissions get deleted and censored.
Sometimes your best talent has a mental illness, how do you manage them? Most just fire that talent when they discover they are mentally ill. It is something that has to stop!
As quaint as it may sound, diet and exercise (the only supplement to that I take is phosphatidylserine now) can really make a difference.
I'm not saying don't do the drugs (especially if your a severe case), but (at least my experience) the drugs are not necessarily as effective as things you can do without all the hassle/expense of prescription drugs.
Reading Whitaker's "The Anatomy of an Epidemic" (https://en.wikipedia.org/wiki/Anatomy_of_an_Epidemic) should be required for anyone considering long-term use of neuroleptics, benzodiazepines, or anti-depressants. And for those who care for them.
I view those who discourage people from taking their meds as the same as people who encourage alcoholics to "just take one drink."
In some cases doctors over prescribe to people who are suffering from situational depression, giving out medication instead of treating the root cause and finding a way to tackle the problems in somebody's life, but for others it is a medical complaint. Without knowing which category somebody falls into its grossly irresponsible to tell them they shouldn't be taking medication which in many cases quite literally keeps them alive.
Over here healthcare is not just another business, it is a public service. We grumble about the NHS but we love it too. With the NHS you don't have to second guess whether that doctor is after your wallet, or even think about it, he/she isn't.
By comparison the American healthcare system is something that, with a British perspective, appears to have something tantamount to 'Münchausen syndrome by proxy'. With the British NHS you can end up on pills all your life but there is not a business case for it. Meanwhile, in America, if you can be signed up for a smorgasbord of uppers, downers and a few off-label side orders for the rest of your days then Big Pharma is happy.
Here is one of my favourite books that describes what goes on:
http://www.amazon.com/Blood-Medicine-Blowing-Deadliest-Presc...
I've heard this particular chestnut often. In so far as I understand, if your doctor does this, they're committing malpractice. I'm not saying doctors don't do this, or someone's doctor doesn't, but this is not the norm. Not by a long shot.
(Caveat: generic mood stabilizers (used for treating bipolar disorder) that are also anticonvulsants have I've heard a bad history of not working like the brand name, First World manufactured originals.)
I've gone back and tried a few, but the only things that seem to have any positive effect are short-acting anxiety medications which I take maybe once every 2 weeks to help with a flare-up. The long-term depression is nearly gone.
I still would recommend that anyone that is in a deep depression that hasn't tried medication before try them, because it works well for most people. But if you are one of the unlucky ones that it does not work for, keep trying, as coming out the other side is definitely worth all the pain and suffering. You also get a wonderfully nice perspective and can empathize with others who are going through it, something a lot of people can't say.
A book I recommended elsewhere in this thread, http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-A..., does an admirable job of researching the history and results (medical, scholarly, social and financial) of psychological drugs in the US.