
Calling for a new approach to depression - MrBuddyCasino
https://www.theguardian.com/society/2018/jan/07/is-everything-you-think-you-know-about-depression-wrong-johann-hari-lost-connections
======
justasitsounds
There seems to be an increasing number of non-academic articles, essays and
books that are expressing the idea that the Serotonin hypothesis of depression
is flawed. It seems like the drug industry just picked up this idea in the 70s
and has been running with it (to the bank) ever since

Anecdotally, I have come to believe that SSRIs have a temporary mood-altering
effect, possibly combined with a placebo effect that wears off over time - as
your body adapts to the induced serotonin imbalance. The only answer from the
medical profession? Increase the dose.

I saw this with my own mother. She went from being a mildly depressed retired
housewife to suicidal within the space of 12 months. She started on low-dose
SSRIs which seemed to work for a while before she regressed. Each time she
started to feel depressed again she would be prescribed with an increased
dosage. This pattern repeated until she was taking the maximum 'allowed'
dosage, by this point she was delusional, paranoid and suffered terrifying,
persecution-style hallucinations - perhaps not surprising seeing how much her
brain chemistry must have been out of whack.

Sadly, I'm making these observations with hindsight, she took her own life in
2015. I wish I could share this article with my dad, if I knew it wouldn't
break his heart. Both she and my father couldn't share with their children how
gravely ill she was until it was too late. They both trusted their doctors
implicitly. What they weren't prepared for was the fact that the theory that
formed the basis of her treatment was, it seems, no more than guesswork
supported only by publication bias, wishful thinking and greed.

Ironically, one of my first web development jobs, way back in 2000, was at a
'medical communications company' where I created an intranet site for GSK
(IIRC) for use by their salespeople to shore up the claims of the
effectiveness of Seroxat/Paxil and counter negative studies. So, I guess that
makes me complicit in all this too.

~~~
dsego
Almost all antidepressants list the increase of suicide risk as a side effect,
which is frightening.

Zoloft for example [1]:

> An increased risk of suicidal thinking and behavior in children,
> adolescents, and young adults (aged 18 to 24 years) with major depressive
> disorder (MDD) and other psychiatric disorders has been reported with short-
> term use of antidepressant drugs.

[1][https://www.drugs.com/sfx/zoloft-side-
effects.html](https://www.drugs.com/sfx/zoloft-side-effects.html)

On a personal note, I am very sorry for your loss.

~~~
justasitsounds
Like all side-effect warnings I'm pretty sure the warnings about increased
suicide risk are only added after the drugs have been on the market for a
while (and having accumulated a few lawsuits). As with the generic 'this
product may contain nuts' warnings on food these smack of post-hoc ass-
covering to me.

While my scepticism of 'alternative' medicine, magical thinking and general
woo-woo is as strong as ever, my experiences of the last couple of years have
really shaken the former certainty I used to express in the rigour of science-
based medicine. I still believe in the method, but the execution seems to
leave a lot to be desired. Not entirely unrelated, I'm reminded why I became
disillusioned with my biochem undergrad studies - specifically the labwork. We
were repeatedly told to ignore results that didn't produce the 'correct'
result and were even docked marks for effectively honest reporting. Although
I'm sure it was mostly crappy technique that was to blame.

Thanks for your kind words

~~~
ianai
I think those side effects are boilerplate across all drugs of the same
action/class. Support for this is in the allergic reaction language. This is
from someone who recently went through many Rxs in search of something that
would work. (The ultimate lesson I learned was to seek professionals that
specialize in whatever the chronic illness may be.)

Maybe science and medicine have much yet to learn or are being led astray by
current theories.

I am sorry for your loss. My own mother has a severe hack and cough from a
life of smoking. I know I’ll miss her deeply when she leaves me someday. I
can’t fathom how painful that must be.

------
ianamartin
The part about funding studies and throwing away the ones that don't say what
they want about a drug is worse than described because a lot of the funding
goes to graduate programs where the students have no choice but to find
results favorable to the drug.

I have an ex-girlfriend that went into the PhD program for Neuroscience at a
reputable university. Her entire degree and living stipend was paid for by a
pharmaceutical company. The company "suggested" that her PhD research revolve
around a drug that lowered aggressive tendencies.

The sloppiness of the study appalled me. I couldn't say that much because she
and I were dating at the time, but it was absurd. There was no funding for
getting a reasonable sample of people. So they went to a halfway house and
brought in 30 males and 30 females. All criminals, all on probation or parole,
all with serious histories of substance abuse, and most of the women were
pregnant.

Almost all of the males dropped out for one reason or another. Many of the
women did as well. I believe the final tally was 3 males and 13 women. All of
whom tested positive for some assortment of drugs.

The sample size is obviously problematic here. What was possibly even worse
was when I would go to the lab and watch this person sift through ECGs. The
test itself that defined aggressiveness was totally ill-defined, and the
neural response to the test was basically, "Well, let's just take a look at
it. Okay, this one looks aggressive. That one doesn't."

It was a total shitshow. The end result? A published paper in a prestigious
journal about how this drug reduces aggressiveness, a PhD, and FDA approval
for the drug.

I hate to identify with conspiracy theorists, and all that. But I literally
watched this process happen with a person I was dating for almost all of it.

When it comes to drugs, you really have to do your own research. Your doctor
isn't going to do it for you. That's the double burn of healthcare in the U.S.
Even when you have it, you can't really trust it. You have to pay for it, you
have to know what's wrong with you, and you have to know what you need. And if
it isn't a drug, then fuck off. You have to pay for it anyway.

People say, "Fuck you, that's one story that probably went badly. Science is
self-sufficient and self-correcting. The plural of anecdote is not data." Fair
enough on all points.

But there is a systematic and broken way of doing science in the medical
industry. And doctors are not scientists and don't really get trained to know
the difference between good and bad science.

~~~
newfoundglory
I don't know if you're aware of this, but drugs don't get FDA approval based
on any single study, let alone the one you described.

------
zaptheimpaler
I totally agree with this, and I will repeat a somewhat controversial view I
hold:

Governments & business owners directly gain power & influence in the world via
their citizens/workers productivity. The western attitude to "mental illness"
is shaped VERY strongly by this - when you get "depressed" working an overly
stressful job with no hope of anything better, it is better to convince the
poor sap that its a problem with THEM rather than a problem with the world.
Then give you some pills to make it better.

This dysfunctional culture will swallow up all your time, force you to work on
things you fundamentally don't believe in, leave you isolated from people and
then tell you its your fault for being depressed. We need to make the world
stop dehumanizing us. Monkeys in cages get depressed.

When 5% of people are depressed, maybe its fair to say they should seek
treatment on their own. When 30%, 40%, 50% of people are depressed.... its
time to adapt the world to fit peoples well-being instead of the other way
around..

------
seibelj
Years of strict exercise, diet, meditation, breathing techniques, various
forms of therapy, and numerous self-help books did not cure my anxiety and
depression. 2 weeks after starting a low-dose (10mg / day) of Lexapro made me
feel better than I had in 10 years.

Don't be afraid of medication if other techniques fail. My life was ostensibly
fine, with a good job, friends, and family. I had a chemical issue, which is
solved to this day with Lexapro. I consider it a drug that saved my life.

~~~
dsego
Glad it works for you. I took a small does for one week. First two days was
great, everything had an aura about it. Also, I felt very warm all the time.
After 3-4 days I lost erections and then just threw them into the trash bin.
Didn't want to risk it. I have a family member who needs viagra because
antidepressants messed up his nerves. Psyhcs will tell you it's temporary,
well, not always, but they won't admit it.

~~~
hndamien
While I am fairly vehemently against them and pro LSD as an option, I tried a
short course of Lexapro and it was mildly helpful for about 3 months. A decade
later I had the audacity to try again under different circumstances. Day 3 I
had the worst and only panic attack of my life and decided to call it a day
and use mindfulness techniques to deal.

------
aaavl2821
One of the biggest reasons that antidepressant meds are the go-to treatment
for depression in the US is reimbursement. This reason is a cause of another
important problem with mental healthcare in the US: shortage of mental health
providers

Reimbursement for psychotherapy has been getting squeezed in the last several
years. Reimbursement for psychotherapy is generally based on time: i.e. $x for
a 30 minute session, $y for a 90, etc. Reimbursement for "medication
management", i.e. prescribing drugs, is not based on time, but generally is a
fixed amount. So the more prescriptions you write, the more money you make.
Psychiatrists therefore focus on meds rather than therapy, as the
reimbursement rates for therapy can't support a practice. Many psychiatrists
don't take insurance at all bc they don't want to be "medication mills", so
they charge $200-600+ per hour for therapy and only rich clients can pay.
Psychologists and other licensed therapists can't prescribe meds, so they do
therapy, but often make less than $60-70k a year. People don't want to go into
psychology / psychiatry because of the stress of dealing with suffering people
without having the tools to help them, and then getting paid relatively little
(compared to other health care professionals)

This results in much of depression and other mental health being treated in
primary care. PCPs aren't trained that well in treating mental health beyond
what pharma sales reps tell them, so they wrote an rx and call it a day. 70%
of patients don't respond to the first trial of antidepressants, but PCPs
don't really know how to handle this

~~~
refurb
Doctors don't make any money from writing a script (beyond the payment for the
consultation). In fact, the would make more money if they used counseling
rather an a drug.

~~~
nasredin
IIRC there is an issue here. Former doctors who now work for pharma companies
and take their peers to dinners and push the new (patented) drugs.

Doctors then prescribe these new drugs perhaps needlessly (Vioxx?) or over
generic ones.

Also in my experience counseling is only affordable to the wealthy or people
in the criminal justice system (where it is already too late IMHO).

------
marian_ge
Dismissing the scientific trials as flawed by cherry picking and then choosing
an anecdotal cow to make a point seems ironic to me. The only thing I can get
from this is that we may not have the whole picture regarding depression and
focusing only on medication is the wrong thing. But as far as I know from
people battling with this is that even in my country the doctors strongly
recommend lifestyle changes and hours of therapy with a psychologist for long
term success

~~~
Sean1708
Yeah the author said something along the lines of

> beyond only the packs of pills we have been offered as often the sole item
> on the menu for the depressed and anxious

several times in that article, and it just doesn't ring true for me. Maybe the
author is specifically talking about American psychiatry or maybe the people I
know were just lucky, but all the people I know that have been to their GP
about depression or anxiety (granted not a huge sample size) were offered CBT
first and foremost and only one of them was prescribed medication at all in
the end.

------
ascorbic
Quite apart from the generally pseudo-scientific content, there is a big part
of missing context in this: the author's background. Johann Hari was first
found to have plagiarised large amounts of his published work over many years,
and then to have used sockpuppet accounts to make negative (and libellous)
edits to the Wikipedia pages of his critics. This is his first major
publication since his disgrace. Is it really that surprising that somebody
whose career was left in ruins is likely to identify hating ones job as a
cause of depression?

------
JDiculous
> 13% of people say they are “engaged” in their work – they find it meaningful
> and look forward to it. Some 63% say they are “not engaged”, which is
> defined as “sleepwalking through their workday”. And 24% are “actively
> disengaged”: they hate it.

In my opinion this should be a national emergency on par with something like
the opioid crisis (a symptom of this). We're a nation of depressed, drugged up
zombies sleepwalking to our unfulfilling office jobs everyday to pay off our
student loan / mortgage debt (yes I know not everyone is in that situation,
but even if only 10% are that's 30 million people).

------
nixpulvis
I've been depressed, and I'll tell you this straight up. If a doctor gave me a
cow instead of the pills, I would have been way better off... ignoring all the
actual problems the cow solved for the rice farmer in the article, just the
honesty of the doctors recognizing the real issue in the right spirit would
have made me laugh, and prolly "cure" me, at least for a little while.

~~~
TheSpiceIsLife
Getting two (sibling, Border Collie x Foxhound) puppies, and taking a boatload
of magnesium and Vitamin D, a fair bit of rock climbing, skiing, jogging, and
weight training, seems to have alleviated me of all my anxiety and depression.

I obtained a prescription for an SSRI from a doctor, sat in the car outside
the pharmacy for an hour staring at the prescription, then drove home. No way,
fuck that those drugs. I've already wasted the better part of 10 years of my
life to meth-amphetamine. I'm gonna work this out without drugs.

~~~
macawfish
YES to magnesium & vitamin D... they must be taken together and work wonders.

~~~
nasredin
I HATE people who put IANAL and other acronym disclaimers everywhere, but I
just feel these type of posts can negatively influence people.

I am glad magnesium and vitamin D worked for you, but some people may need
prescription medications from a psychiatrist.

~~~
macawfish
There are likely some great psychiatrists out there. If you can find one, and
the medication is working for you, go for it.

If you like academic legitimacy, check out this article:

 _Rapid recovery from major depression using magnesium treatment._

[https://www.ncbi.nlm.nih.gov/pubmed/16542786](https://www.ncbi.nlm.nih.gov/pubmed/16542786)

I'll admit, I'm very biased. My sister's pediatrician prescribed wellbutrin to
her for weight loss ( _in middle school_ , when she wasn't even unhealthily
overweight). Soon after, she became suicidal during a long road trip and
attempted to kill herself by taking the whole bottle. This just led to more
psychiatric intervention and more SSRIs. A few years later, my mom asked me to
sit in on her therapy session, to see what I thought of "Dr. Dan", her
psychiatrist at the time. This man sat there asking prying, dark, loaded
questions for half an hour, pushing her further and further into silence and
irritation.

I've also had some very positive experiences with therapists. I know now how
to recognize a therapist/psychiatrist who is out of their element, but a lot
of people just put blind trust "the psychiatrists". To me, that's very
dangerous!

------
pmoriarty
_" And that’s when, after two more years studying civil servants, he
discovered the biggest factor. It turns out if you have no control over your
work, you are far more likely to become stressed – and, crucially,
depressed."_

I wonder how this research squares up with the so-called Executive Monkey
experiment, which found that it was actually the monkey with more control that
had more stress.[1]

[1] -
[https://en.wikipedia.org/wiki/Ulcers_in_Executive_Monkeys](https://en.wikipedia.org/wiki/Ulcers_in_Executive_Monkeys)

~~~
nasredin
I love reading about experiments performed in the 50s and 60s before all those
pesky Ethical Review Boards(?)

>In an early version of the study, Brady placed monkeys in 'restraining
chairs' and conditioned them to press a lever.[2] They were given electric
shocks every 20 seconds unless they pressed the lever during the same time
period. This study came to an abrupt halt when many of the monkeys died from
perforated ulcers.

------
thaw9876
> We need to feel we belong. We need to feel valued. We need to feel we’re
> good at something. _We need to feel we have a secure future._ And there is
> growing evidence that our culture isn’t meeting those psychological needs
> for many – perhaps most...

This (emphasized) is what I think is causing my increasing anxiety and
depression. I look around at people, talking loudly, showing off, taking
selfies, buying expensive crap they don't need from expensive shops, etc. I
try to puzzle out why they're so happy, they all seem so superficial, and I
can't understand why they don't feel miserable about the people less fortunate
than them who live right next door, the people serving them, who are all
struggling to just get by and by all measures increasingly failing. I really
want to live in a more equal society that takes care of all citizens.

~~~
flowless
Same here. One of the most disturbing scenes I'm witnessing like every night
is couple of homeless people sleeping in front of the church while each
morning there are these noble ignorants walking around them who even call them
selves Christians..

Anxiety is just another term for caring too much in some cases (This was
mentioned here on HN last time I was reading similar discussion).

~~~
nasredin
Disagree.

I think you are descibing empathy and selfishness, not anxiety.

Anxiety and empathy are probably somehow connected, but they are different
things.

------
Kluny
Suggest alternate title: Many people are depressed because they lack control
over their work.

~~~
kiliantics
Yes the most important part in this article to me was how a group was able to
alleviate the stress of their working lives by forming a co-operative together
with no hierarchical power relationships, thus controlling their own
workplace.

------
dboreham
I'm surprised to see this as "new" because there has been work published since
the late 60's [1] and widely known since the early 90's [2] showing that
depression is often no more and no less than "having depressing thoughts".
That is, if you can persuade the person to believe that they don't have a good
reason to be depressed, they stop showing signs of depression.

[1]
[https://en.wikipedia.org/wiki/Martin_Seligman](https://en.wikipedia.org/wiki/Martin_Seligman)
[2]
[https://books.google.com/books?id=qreACUdDAc0C](https://books.google.com/books?id=qreACUdDAc0C)

~~~
taneq
I thought that, if you're actually depressed, it kind of implies you don't
have "good reason" to be? I mean, if you're feeling terrible because bad
things are happening to you, you're not depressed, you're just legitimately
miserable.

~~~
newfoundglory
I believe it’s called endogenous v exogenous depression. Someone who is
considering suicide because they failed an exam is not very well described as
“just miserable", even though there's an exterior trigger for their feelings.

------
wu-ikkyu
It still seems many people believe there is strong scientific evidence to the
"chemical imbalance" theory as an independent cause of depression, which is a
myth.

It is a paradoxical issue though, because chemicals can indeed play a crucial
role to overcoming depression.

~~~
nixpulvis
What even is a chemical anyway... honestly people throw this word around in
these kinds of contexts with all kinds of meanings.

~~~
wu-ikkyu
Great question! Though it would seem we are delving into the realm of
metaphysics, which is unfortunately taboo for modern psychiatry.

~~~
nixpulvis
I mean, are the electronic signals that constitute my nervous system a
"chemical balance" (I could make that argument), well then SURE all depression
is completely 100% chemical...

But I digress.

------
qwerty456127
Nevertheless, all the major emotions/moods one can feel: sadness, joy,
laziness, vigour, fear, enthusiasm, anger, limerence etc are almost nothing
but chemical conditions. If you feel panic or are angry at somebody - that
doesn't necessarily mean you are in danger or that somebody is an asshole -
that means you have elevated level of norepinephrine and/or low serotonin
and/or something like that. Feeling lazy doesn't mean you have fallen to the
sin of sloth but that you have low levels of thyroxine and/or dopamine and/or
norepinephrine and/or serotonin and/or something else. That's a huge problem
the majority of people don't understand this, just keeping this in mind makes
the life a lot easier for you, your family and everybody around. Also it
usually is enough to take something as natural, cheap and harmless as
L-tryptophan (an essential amino-acid, the precursor to 5-HTP and serotonin,
easily available as an over-the-counter supplement and found in many foods
naturally) to fix the problem, SSRIs and benzodiazepines are not necessary in
every case.

------
milankragujevic
I am disenhearted by the apparent pseudo-scientific thinking in the comments
on this article, and how it'll "be better if you just go workout and eat
better", which might work for some people, but not for everyone. If there was
a scientific study about changing life habits to stop depression, I'd bet that
it would have the same amount of effectiveness or even less than SSRIs. I
myself have been "miraculously" cured from depression by the most ridiculed
profession in modern medicine, psychiatry, and with "poison" that was supposed
to ruin my life and make me kill myself. Basically, aripiprazole and
fluoxetine helped me, and help me live life, work and be happy. There was
nothing wrong with my life until one day I tried to kill myself, and I was
very resistant to treatment because of years of people's anecdotes how
psychiatrists were crazy, were "out to get them" and "chemically lobotomize"
them. This is bullshit, and we all know it, during my stay in a hospital I
have seen many cases of teenagers who were "beyond repair" get "fixed" with
medications, and would you look at that, 3-4 years on, they haven't regressed
(I kept in contact). Neither have I. It's dangerous to spread conspiracy
theories to impressionable and vulnerable minds, and you should think twice
before dismissing the whole modern science of psychiatry, just because you
fell that hippie life and smoking pot is the way to fix anyone's life. I don't
care about the downvotes, but had to get this off my chest.

~~~
zbobet2012
There are many, many studies on changing life habits (working out) as a
methodology to treat depression. It is actually _as effctive_ as SSRI's, and
MORE effective for a longterm treatment for depression.*

However, _not all treatments work for everyone_. Certain SSRI's work for some
and not others. This also holds for exercise.

[1]
[https://www.ncbi.nlm.nih.gov/pubmed/26978184](https://www.ncbi.nlm.nih.gov/pubmed/26978184)
[2]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/)

~~~
nasredin
Not an expert.

Low energy often comes with depression. So it's not easy as telling a
depressed person to "do more exercises".

Depression is "invisible". I like to think that being depressed is like having
a broken leg. You can't just get better by yourself, you need proper medical
treatment.

~~~
Ntrails
Also Not An Expert.

Replace the broken leg with a generic bad back (non surgical) and it's not a
bad equivalence.

Medical advice in many cases is to do things which hurt (exercise, stretching,
lose weight) otherwise the back won't get better, but doing nothing will
almost certainly lead to stagnation or a worsening of the condition. You can
take pills which may reduce the pain, but those are not really a long term
solution on their own.

I don't wish to diminish how hard it is (in either case, intentionally causing
yourself discomfort is utterly exhausting in every way). It often is both
possible and beneficial so be wary of writing off a school of thought
entirely.

------
blhack
There are two things that both get called "depression". Like so many other
confusing things, this all is the result of fuzzy language.

There is depression: the feeling of being sad. This can be triggered by all
sorts of environmental factors, and is ultimately a psychological disorder
that can be solved by changing environment variables.

There is also depression: the neurochemcial/neurophysiological disorder that
has depression (sadness) as one of its symptoms.

It can be treated with various (miracle) drugs.

\--

People who want to fight against the idea that these modern miracles (drugs
that treat depression) are effective treatments for this debilitating, but
curable disease, belong in the same category as flat earth era, anti-vaxxers
and now, apparently, "raw water" fans/advocates.

Required viewing: a lecture on this topic by somebody who knows more about it
that anybody else who is currently alive:
[https://youtu.be/NOAgplgTxfc](https://youtu.be/NOAgplgTxfc)

~~~
tcj_phx
> People who want to fight against the idea that these modern miracles (drugs
> that treat depression) are effective treatments for this debilitating, but
> curable disease,

The modern miracle drugs that effectively treat and cure debilitating
depression are not SSRI's. Whatever benefits SSRIs have are probably a result
of their influence on neurosteroids:

>> Certain antidepressant drugs such as fluoxetine and fluvoxamine, which are
generally thought to affect depression by acting as selective serotonin
reuptake inhibitors (SSRIs), have also been found to normalize the levels of
certain neurosteroids (which are frequently deficient in depressed patients)
at doses that are inactive in affecting the reuptake of serotonin. This
suggests that other actions involving neurosteroids may also be at play in the
effectiveness of these drugs against depression [0]

[0]
[https://en.wikipedia.org/wiki/Neurosteroid#Role_in_antidepre...](https://en.wikipedia.org/wiki/Neurosteroid#Role_in_antidepressant_action)

Other miracle drugs are also helpful for addressing the cause. Big Pharma
doesn't care about cause/effect, they just want patients on maintenance
treatments.

Depressed people usually have some sort of metabolic problem, caused by
thyroid problems, inadequate diet, etc. Emotional stress is usually a major
factor too.

> belong in the same category as flat earth era, anti-vaxxers and now,
> apparently, "raw water" fans/advocates.

Where do you belong? Are you a tireless advocate for the status quo?

~~~
newfoundglory
> Depressed people usually have some sort of metabolic problem, caused by
> thyroid problems, inadequate diet, etc.

In my experience, thyroid etc are the fist things tested for before suggesting
depression. Do you have any kind of evidence for that argument ?

------
solarkraft
Thanks for changing the senseless title in the submission.

------
drumhead
I'd like to think that medical professionals and academics in the mental
health field have probably been thorough enough in their research to have
looked at these finding over the years. I somehow doubt a person whose
graduated in Social and Political Science and has no medical or scientific
background might actually know what they're talking about in relation to this.

Interesting thing about the author. He was a rising journalistic star in the
UK. He'd won awards was regularly on TV and radio, until it was discovered he
had been plagiarising others for a lot of his articles. It was also found that
he had been editing wikipedia articles to attack people who critisised him. An
interestingly tragic character.

[https://en.wikipedia.org/wiki/Johann_Hari](https://en.wikipedia.org/wiki/Johann_Hari)

~~~
ekwelio399
Tenured professor of psychiatry here. I'll give you the summary of research on
depression:

1\. Emotional state is like blood pressure. It's a continuously varying thing.
There is no discrete depressive disease state, just an extreme end of a
continuum.

2\. Just like blood pressure, though, very high blood pressure (or low)
represents an illness state, a potentially very serious one. The etiology is a
different matter. It may be due to sociocultural processes, or existential
threat, or genetics, or neurological insults, or all of the above, each in
some measure.

3\. When we talk about "depression," it's usually a shorthand for a broader
set of problems, related to lack of well-being, malaise, despair, sadness,
anxiety, fear, and so forth.

4\. The particular cocktail of emotions for each person is different though.

5\. The best meta-analytic evidence suggests that antidepressants work, but
not nearly as well for people as we were led to believe, and there's huge
publication biases. Some drugs might not work at all. Some drugs work for some
people; those same drugs might not work for other people at all.

6\. Serotonin per se probably has nothing to do with the effect of
antidepressants.

7\. Psychotherapy works as well or as poorly as drugs on average, with some of
the same publication biases. This is considered against many different types
of controls, including placebo controls and various types of behavioral
controls. Being wait-listed is the worst intervention of all, though.

8\. Different psychotherapies do not differ in efficacy on average. The
superiority of cognitive-behavioral therapy, etc. is a myth. Different
therapies might differ for particular individuals, though, and there are some
basic ingredients that seem to be necessary for efficacious therapy. The
effect of therapist dwarfs the type of therapy (that is, some therapists are
really really good, and others are less good, and that is much more important
to outcome than type of therapy per se).

9\. The best outcomes are generally therapy and drugs in combination, and if
one thing doesn't work, trying different things will often work eventually.

The recent history ("recent" being the last 30-40 years) of psychiatry and
clinical psychology is dominated by economically and politically-driven
reductionism and oversimplification, within the realms of therapy as well as
pharmacology. A lot of these dynamics are driven by a desire to present as
rigorously scientific, wrapping ones' selves in banners of other disciplines.
The problem with this is behavioral science is its own thing; it resembles
other disciplines in some ways, but not in others (much like every other
domain of science).

~~~
jdietrich
> Different psychotherapies do not differ in efficacy on average. The
> superiority of cognitive-behavioral therapy, etc. is a myth.

Slight nitpick: CBT has a much larger and more reliable body of evidence than
most other therapies. It's probably no more effective than other therapies,
but it is very cost-effective, mainly because of the short duration of
treatment. There is some evidence to suggest that self-guided or internet-
delivered CBT may be as effective as traditional CBT delivered by a trained
clinical psychologist, which would be a huge win in terms of cost and
availability.

On a personal level, I'd recommend trying a wide range of psychotherapies if
you can afford it. On a societal level, I endorse mass adoption of CBT. It's
not necessarily the best therapy, but it's the easiest to deliver at scale.
Access to treatment is _the_ issue right now, especially in lower-income
countries.

------
com2kid
This explanation does not work for all types of depression. There are people
who have wonderful lives, fulfilling jobs, happy families, who are still
depressed.

We need to be more careful in our language, the word depression has become
overused, much like the drugs used to treat it.

~~~
mabbo
That's how I've often described it before. Feeling like shit when your life is
terrible is normal. Feeling like shit when your life is awesome is not.

The problem is that the pill often works regardless of why you feel like shit.

~~~
wu-ikkyu
>Feeling like shit when your life is terrible is normal. Feeling like shit
when your life is awesome is not.

Could it possibly be that our idea of an "awesome life" is mistaken?

~~~
nixpulvis
BOOM, exactly.

------
foobarbecue
Why did my comment get flagged? I assume this was a mistake, so reposting:

tl;dr: Many people diagnosed with depression are actually just sad because
modern society is kinda lame.

(The article argues this point cogently, and I agree with it.)

[I slightly edited this because I think people thought I was saying that I
think all depressed people are faking or something]

~~~
EGreg
I found, over the years of being on HN, that there's a sort of forceful
response that always comes to these types of comments about depression, along
with downvoting. The responses say basically,

"Don't talk about what you don't know. Many people have real, chemical
depression, and your comment that it's a product of life circumstances is _not
helpful_ ".

I was always a but puzzled about the regularity with which that above formula
appeared on HN. Sure, many entrepreneurs and especially developers lead
lonely, stressful lives. I am a developer and entrepreneur myself!

But I also felt there is a sort of "groupthink" or "bullying" element to this,
because there was hardly much substantive discussion about facts or statistics
or science, in effect it was shaming the commenter into shutting up.

This bothers me. I like to see real fact based discussion when there is
disagreement. Not just downvoting and vague assertions.

In this case I am sure you were downvoted by that exact same sentiment. Even
if you had summarized the article, the content of the summary was enough to
trigger the downvote.

~~~
foobarbecue
Oddly, it was upvoted twice /and/ flagged. I guess anyone with enough
reputation can bury things just by hitting a "flag" button.

~~~
greenyoda
It could have been flagged multiple times (flags are additive). Even articles
that have hundreds of upvotes can be killed by flagging if enough people flag
them.

~~~
foobarbecue
Is flagging the same thing as clicking the [-] button? Is this explained
somewhere? My flagged comment has +2 points, and my unflagged version of it
has -2 points. Very confusing, and if I did something wrong, nobody is telling
me what it is. I can't find any documentation for HN, which is a little
ironic...

~~~
grzm
The [-] collapses your view of the thread. The flag link appears when you have
sufficient karma (I don’t recall the threshold). Click on the time stamp for
the comment you want to act on. If you have enough karma, the flag link
appears between the “parent” and “favorite” links.

