Depression Confessional Culture Obscures the True Nature of Mental Illness
crikey.com.au
crikey.com.au
http://psychcentral.com/lib/the-depths-the-evolutionary-origins-of-the-depression-epidemic/00018693
To me, the biggest gap in the mainstream theory is that it claims that depression is qualitatively different from sadness, and yet I have never seen any scientific article that provides evidence of this. The usual argument that is given for this distinction is that, unlike merely being sad, depression produces extreme feelings of helplessness, pessimism and inability to act. And yet what if these were actually just extreme versions of things that already go along with what we call sadness? That is, what if mild sadness and mild depression were the same thing, and severe depression was categorically different from mild sadness only because it was more extreme?
If you're instead trying to say that they're biologically / mechanically similar phenomena, well, that's a different discussion we could have.
Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful. I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point.
The main ones are
1) Depression (unlike sadness) is not caused by circumstances that cause a person to be unhappy.
2) Depression (unlike sadness) can only be cured by addressing to root (medical) cause of unbalanced brain chemistry.
3) Depression (unlike sadness) either is not curable, only the symptoms can be cured, or people who recover are prone to relapse.
>Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful.
No, but maybe I've experienced things just as bad? I don't really know, but I also don't know how you claim to be able to compare your experience to mine.
I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point.
It's a logical fallacy to think that people do/should only make arguments with some end goal. My goal is to express my opinion on the nature of mental illness. Another fallacy is that arguing that "X is true" can be immoral, because of X were true, then some immoral consequence would follow. If I am right, we should still be just as compassionate towards other people's problems.
You can be compassionate and understanding towards someone's problems without categorizing those problems as a medical illness. Similarly, you can use this categorization as an excuse not to be compassionate, e.g. treating a person as irrational or untrustworthy because they have had a mental illness in the past.
Yes - does it pose a risk of harm to yourself or other people; does it interfere with your day to day life? These quality statements are used as part of the process of assessing whether someone needs or wants a treatment, and they should be common across all forms of mental illness. (EG people with auditory hallucinations often go unmedicated because they can live with their voices.)
> You can be compassionate and understanding towards someone's problems without categorizing those problems as a medical illness.
Compassion does not treat depression, although it's important part of preventing depression. Talking therapies like CBT are pretty structured, and the evidence says they seem to work. We know the counseling generally doesn't, and can be harmful. And also, if a person needs treatment then they might need money to pay for that treatment and protected time off work to get treatment. Calling dysfunctional forms of sadness "depression" is partly a bureaucratic measure we take to fund treatment and protect people from losing a job.
Strongly agree with your last sentence. A few people on HN equate mental illness with violence but mental illness does not predict violent behaviour (drug addiction; or previous violence are much better predictors, and if you have a combination of either / both of those and a mental illness that's a better predictor, but merely mental illness itself isn't predictive).
Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for.
>Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for.
On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness. I don't see any logical connection between the views that(1) severe depression is a serious problem, and (2) severe depression is on a spectrum where the milder versions are not distinguishable from being unhappy or "in a rut".
[0] http://www.nimh.nih.gov/health/statistics/prevalence/major-d...
The take-away here is not really whether the condition is or is not physical, but rather, what the labeling of it as physical does to the perspective of its sufferers and its effect on their prognosis.
Pyschological issues of this nature are a curious form of disease, in that the mental models of their sufferers form a feedback loop with the condition itself. Whether or not depression is physical, thinking that depression is physical has a tangible effect on the condition itself, one that this author and I would argue is sometimes (though not always!) negative.
However, it is in the interest of pharmaceutical companies that it be thought of as purely physical, with purely physical treatments. And it can be argued that this mode of treatment, and this mental model in the minds of the sufferers is self-reinforcing. Because it is presented as a physiological ill, depressed persons see it as such, and eschew or don't fully invest themselves in alternative solutions, which make them not work.
The sum of all of this is that depression is one of the few diseases that is actually itself shaped by the marketing of its treatments. Which is both interesting and troubling, given the relative inability of the current regulatory framework to cope with this systemic condition.
(This has pretty much been said on HN before.)
Is this even meaningful? What you're saying is 'emotions are complex so feeling X might just be a more extreme version of Y even though it sometimes shares no properties with Y whatsoever' - doesn't that mean I can now say any experience is just an extreme version of any other?
Schizophrenia is really a lot like extreme happiness! You have any problem with that?
>On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness.
I didn't say put them in 'special categories' (most of the 'mainstream' attitude I experience is that I'm full of shit and should pull myself together, by the way), I said be careful and don't just speculate as if it were a folly in a public place like this, since you risk coming off like you're downplaying it. You can categorise however you like, but _back it up_ and have a little compassion. This isn't a programming language pissing match.
Saying severe depression is a more extreme sadness potentially implies you should do some lovely happy nice things to fix it like you can with milder sadness - much like the usual bullshit I hear about how if only I did more exercise it'd all be fixed and really you can fix it if you just put some effort in! Never mind that the lead PT of the biggest fitness brand in the UK jumped off a cliff, or that many people with seemingly great lives have committed suicide...
Saying something is just more of something else, implies that usual fixes apply, just you need to do more.
I'm not saying you think any of this, but that you need to tread carefully - these are actually I think (and experience) most people's views anyway, even if they don't want to say it, so both for depressives and those who might interact with them, you're potentially doing harm - is you waxing philosophical of more value than that potential harm?
Saying severe depression is a more extreme sadness potentially implies you should do some lovely happy nice things to fix it like you can with milder sadness - much like the usual bullshit I hear about how if only I did more exercise it'd all be fixed and really you can fix it if you just put some effort in! Never mind that the lead PT of the biggest fitness brand in the UK jumped off a cliff, or that many people with seemingly great lives have committed suicide...
I think this gets to the core of our disagreement. You are implying that people without mental illness experience life in a way that is simple and intuitive. If you are unhappy, do more exercise. If you have a "seemingly" good life then you won't want to commit suicide.
There is a lot of discussion on introversion on HN, and one interesting post I read was saying how the advice to "put yourself out there" was not good because shallow interactions with other people could be just as unsatisfying a no interactions. The advice was to find ways to connect with people at a deeper level.
Similarly "do more exercise" might be simplistic and bad advice for many people, not just the severely depressed. And people with seemingly great lives might commit suicide because they are deeply unhappy or dissatisfied about their lives. Do you honestly think that just because a person has the appearance of a great life, that they must be happy?
It might seem like that to you, but the two don't seem that similar to me. Differences include the fact that you may be able to will your way out of your (somewhat healthy) distraction - or think clearly about it, care about it, or register it happening at all - while this is largely not the case regarding emotional numbness (pathology).
I think this gets to the core of our disagreement. You are implying that people without mental illness experience life in a way that is simple and intuitive. If you are unhappy, do more exercise. If you have a "seemingly" good life then you won't want to commit suicide.
I don't think that's what he's implying at all. Rather, I think he is implying that those that have not had to struggle with depression has another perspective entirely, and thus have a very hard time intuiting what dealing with mental illness is like. That's why you get that kind of simplistic "solutions": those that suggest them usually have no experience with or knowledge of the pathology in question, and are basically thinking of how they would attempt to remedy the situation (unknowingly basing their whole plan on how a healthy mind works).
There is a lot of discussion on introversion on HN, and one interesting post I read was saying how the advice to "put yourself out there" was not good because shallow interactions with other people could be just as unsatisfying a no interactions. The advice was to find ways to connect with people at a deeper level.
Apropos of introversion; there seems to be a great deal of confusion surrounding the term, particularly in relation to insecurity and social anxiety (as with terms that have their meaning muddied by colloquial misuse.)
Similarly "do more exercise" might be simplistic and bad advice for many people, not just the severely depressed. And people with seemingly great lives might commit suicide because they are deeply unhappy or dissatisfied about their lives. Do you honestly think that just because a person has the appearance of a great life, that they must be happy?
Again, lolo_ is talking about why "do more exercise" is bad advice in the context of attempting to cure the perceived "sadness" of an individual suffering with depression. Healthy subjects, on the other hand, will generally see a rise in mood (short term). Depressed subjects will subsequently return to their baseline of "shitty" - if they ever experience an effect in mood at all. And regarding people with seemingly great lives committing suicide: Most of these would likely be diagnosed with some sort of psychopathology (although suicide itself might be debatable on a more philosophical level.)
IMO most cases of depression are caused by life events. That opinion is based on seeing a number of people close to me suffer from it, and recover. Generally it is not entirely obvious to the person what is causing the depression, but looking closely at their life usually pins down a cause. Generally it is something along the lines of working in a job that you don't like, being in a relationship that isn't working, excessive stress/burnout, or not having a purpose in life, or some combination of these factors.
> IMO most cases of depression are caused by life events.
This is called "reactive depression". Do you have any real numbers, or are you just going by the people who you know? Some people mask their depression.
I'm not necessarily saying it does. There may be different types of depression. However I'm saying that this particular type of depression that I experienced definitely was extreme sadness, and it's pretty obvious that that is the case if you have experienced it. It's like saying that a colour is a slightly darker shade of blue.
>This is called "reactive depression". Do you have any real numbers, or are you just going by the people who you know
No, it is just an observation of people I know who have had depression.
When someone says "all swans are white" someone saying "my swan was black" is useful because it makes you realise that maybe you're wrong and need to rethink. someone saying "my swan is white and I've seen some swans my friends own that are white" is less useful because it doesn't provide much on top of what you've already said.
The point I was making was to contradict the idea that it can _only_ be described as extreme sadness, but in no way discounts that as an experience.
Sorry you got downvoted for that, I for one found our different experiences of this disease quite interesting! Though I'd much rather nobody experienced it...
I realise that my post does sound critical. Sorry for that -- I didn't intend that harshness.
But then again this kind of discussion frequently gets muddied by colloquial use of the term "depression".
Well, that's just it though; They appear to be a major causal factor. They might be. But is there any reason for us to believe so, other than the observed correlation of some stressor with the onset of an episode? And even then: do they cause or trigger the illness?
Or maybe that's what you mean - that a life event triggers the episode, not that the traumatic event is the genesis of the illness?
I'm not entirely sure what your differentiation is between "trigger" and "genesis" in this case. Can you explain?
My point, summed up, is one regarding definition.
Maybe it's just pedantry, but I find that your use of cause (what I also describe as genesis) sort of implies that it is a progenitor - that it is a starting point of sorts.
And what I'm suggesting is that there are other factors at play (biopsychosocial model) long before the culmination of the disease in a major depressive episode - provided we are still talking about the term "depression" as in "major depressive disorder."
You could try pointing them to this, which shows that evidence is unclear whether exercise works or not to treat depression.
http://www.cochrane.org/CD004366/DEPRESSN_exercise-for-depre...
> When only high-quality trials were included, exercise had only a small effect on mood that was not statistically significant.
Sometimes compassion means saying 'okay, I understand, that sucks?'.
But I don't think normal emotions are categorically distinct from medicalized emotional states: both are chemical or electrical processes. It seems you disagree. Am I misinterpreting your position?
But "physical" somewhat captures the medical view on depression, as something distinct from the ordinary spectrum of "healthy" emotions, and with causes that are primarily internal not external (although, as you say, all thoughts and emotions are ultimately mediated through physical processes in the brain).
So my point wasn't that sadness is non-physical, but rather all experiences are physical, and most experiences belong to the spectrum of human emotions, which are influenced by external and social events, thought not always in the most obvious way (hence my opposition to the "just get over it" strawman, since "just get over it" might be a bad response to mere sadness too).
I also don't have a strong opinion on chemical intervention, except that I would hold them to a higher standard of evidence since I have a stronger prior on the root cause being social and emotional, rather than a congenital inbalance in brain chemistry. It's plausible that they work, and if they work, they should be used.
What? Mainstream firstline treatment for depression is a talking therapy. This rejection of the physical basis is written into government provided guidance (see eg UK NHS guidance for depression and anxiety).
Studies do show that, on average, antidepressants barely outperform placebo. However, this is because the effects of antidepressants are correlated to symptom severity, so averaging the entire population together shows virtually no difference. This certainly supports less widespread use of antidepressants than has been common in recent decades, but not that antidepressants are useless. It's not like the evidence generally shows that psychotherapy is much better, either. It's prescribed so much less not out of some ideological antipathy for introspection and hard work, but because it's not generally any more effective, costs far more, has much worse compliance, and is less readily available (especially in smaller cities and rural areas) than generic drugs. The dirty little secret of psychiatry isn't that SSRIs don't work; it's that everything sort of works, but any single thing doesn't work very well for most patients, and there's no validated model that predicts which treatment is likely to work for which patient.
In my opinion, the biggest problem with studying depression is that the diagnosis of depressive disorders is tremendously unreliable. Virtually all of their symptoms overlap with "sickness behavior", which is triggered by dozens (if not hundreds) of different physiological diseases. Implicit in the diagnosis of a mood disorder (actually explicit in the DSM, but people are rarely told this) is that those diseases have been ruled out as the underlying cause. In practice, this rarely happens. Doctors will do some perfunctory screening for things like hypothyroid and hypogonadal disorders, but those screening tests have very poor sensitivity and only cover a handful of common causes of depressive symptoms. If you're lucky, you might get an actual formal screening for neurological disorders. Initial screening for sleep disorders is mostly done with crappy questionnaire scales that disproportionately focus on superficial aspects of stereotypical presentation ("Do you snore?"). In a nutshell, being diagnosed with a depressive disorder has little inherent meaning beyond your GP/PCP running out of ideas or patience. In turn, any given study population of "people with depressive disorders" is unlikely to actually be homogeneous in the origins of its depressive symptoms.
I sometimes wonder if all long term improvement in all treatment modalities can be attributed to The Placebo Effect, poorly designed/collated drug/treatment studies, and the brain repairing itself with time? My view on Psychiatry is if you don't have the money to see one; you just might be better off on the long run?(That is assuming you are not suicidial, or psychotic?)
I wish the profession well, but you have not come a long way baby! I do think any patient that has been on a psychotropic drug(especially the addictive ones) a long time, should be able to get that particular drug without seeing a Psychiatrist. I know that will never happen on the U.S.
After hearing that Robin Williams committed suicide and the last tabs open on his IPad were the side effects of the various drugs he was taking, I wonder if he would still be alive if he didn't have access to the best Psychiatrists?
Some cases probably can, but it's not very plausible that such things explain all treatment effects, which are occasionally quite dramatic. Also, many studies include a "waiting list" group to control for the effect of simple passage of time. There are of course many, many, many poorly-designed studies out there; this is not by any means unique to psychiatric drugs, or even medicine in general.
> I do think any patient that has been on a psychotropic drug(especially the addictive ones) a long time, should be able to get that particular drug without seeing a Psychiatrist. I know that will never happen on the U.S.
As far as I know, any licensed MD/DO can prescribe psychotropic drugs in the US. Some choose not to prescribe some classes of drugs (e.g. antipsychotics, MAOIs) because they tend to have more risks associated with them. However, the same can be said for psychiatrists. There are a few psychiatrists who explicitly refuse to prescribe drugs at all, except in the process of discontinuing a pre-existing treatment. Many doctors will also refuse to prescribe the more addictive drugs out of fear of enabling addiction (this is a huge problem for people with chronic pain, as is the FDA's requirement of "abuse-resistant" pills for oxycodone that just happened to be announced on the same day as the original OxyContin patent expired...)
> After hearing that Robin Williams committed suicide and the last tabs open on his IPad were the side effects of the various drugs he was taking, I wonder if he would still be alive if he didn't have access to the best Psychiatrists?
There's a risk of iatrogenesis for treatment of virtually any condition. But I think it's far more likely that the drugs in question simply didn't work for him, or stopped working suddenly (this can happen after long periods of treatment with psychotropic drugs, and as far as I know most patients aren't warned about it; I certainly never was).
Most long term pain should not be treated with medication. That medication should be used short term to allow the sufferer to take part in rehabilitation.
Addiction to painkillers that do not work is a big problem for people with chronic pain, and now they not only have the chronic pain but also an addiction.
There's a segment on this radio programme where they visit a pain clinic in Bristol (UK) to talk to people who are taking huge amounts of opiod pain killers and not getting any relief from their pain.