
Medical research: If depression were cancer (2014) - amelius
http://www.nature.com/news/medical-research-if-depression-were-cancer-1.16307?WT.mc_id=FBK_NatureNews
======
jarmitage
The big shift that's taking place is the gradual removal of nosology (disease
classification) from its pedestal in psychiatry - naming symptoms as the
foundation of all practice and services, which no other area of medicine does
anymore - and replacing it with a _scientific_ framework for discovering
dysfunctional mechanisms at every level from genetic to neural to behavioural.
This was started by Thomas Insell / NIMH (named in the article) and has been
followed in the EU.

The framework is called RDoC and you should familiarise yourself with it if
you've been influenced by psychiatric literature or practice as to your own
mental health.

TLDR General argument:
[https://www.youtube.com/watch?v=PeZ-U0pj9LI](https://www.youtube.com/watch?v=PeZ-U0pj9LI)

More in-depth presentation:
[https://www.youtube.com/watch?v=hU_5i2clSKI](https://www.youtube.com/watch?v=hU_5i2clSKI)

Slightly more technical introduction:
[https://www.youtube.com/watch?v=OyGt8-ddacA](https://www.youtube.com/watch?v=OyGt8-ddacA)

Google Scholar search:
[https://scholar.google.co.uk/scholar?hl=en&q=rdoc](https://scholar.google.co.uk/scholar?hl=en&q=rdoc)

RDoC @ NIMH: [https://www.nimh.nih.gov/research-
priorities/rdoc/index.shtm...](https://www.nimh.nih.gov/research-
priorities/rdoc/index.shtml)

RDoC inspired EU project: [http://www.roamer-mh.org/](http://www.roamer-
mh.org/)

Interested if anyone here has an inside take on RDoC.

~~~
igravious
Thank you for more or less responding to my comment elsewhere in this post.
I've watched the first two vids, looking forward to the rest of your links.

Diagnostically RDoC (Research Domain Criteria) looks like a welcome overhaul
of the increasingly derided DSM.

Them's a lot of circuits: [https://www.nimh.nih.gov/research-
priorities/rdoc/units/circ...](https://www.nimh.nih.gov/research-
priorities/rdoc/units/circuits/index.shtml)

~~~
jarmitage
You're welcome. RDoC was tactically proposed just before DSM5 was published
[1]

For comparing RDoC and DSM there are some good books published recently:

The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel
[https://www.amazon.com/dp/B00U4JLKM4](https://www.amazon.com/dp/B00U4JLKM4)

Alternative Perspectives on Psychiatric Validation: DSM, IDC, RDOC, and Beyond
[http://www.amazon.com/dp/B00Y355QZC/](http://www.amazon.com/dp/B00Y355QZC/)

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

------
wapapaloobop
It's becoming increasingly taboo to suggest that depression and other mental
disorders are not _diseases_ per se but may arise purely from the use of the
mind. This in turns depends to some extent on a person's ideas and not solely
(or even at all) on the presence of pathogens, tissue injuries, faulty genes,
etc (though there may be medical consequences).

There could be important social reasons for this taboo. Perhaps it helps
people suffering from disorders to get more practical help and sympathy
(instead of righteous indignation, unemployment and ostracism).

However, without intellectual honesty there's less hope in the long term of
finding solutions to these problems.

~~~
jdpigeon
Well, it's complicated, because although you might get depressed to issues of
the mind, once that switch has been flipped in your brain, then you do have a
biologically-mediated disease and you're often totally fucked without some
kind of medical intervention.

~~~
mr_tyzic
Everything in the mind is biologically mediated. That doesn't make every mind
problem a disease.

~~~
reverius42
Doesn't it? Replace the word "mind" with "body" and it seems like the very
definition of disease.

~~~
mr_tyzic
By that argument, if you're grieving the loss of a loved one, deciding whether
to marry, struggling to write a novel, or even fixing a bug in a computer
program, you have a disease. All those presumably have some biochemical
correlate.

------
maria_
As someone who suffered from a major depressive episode that nearly cost me my
life, I certainly acknowledge it as a serious disease no different than
cancer.

But thinking of it purely in those terms implies that the development of
depression can be attributed and therefore remedied by addressing chemical
irregularities in the brain. I used to believe that. It put me under stress
and fear that somehow, randomly, because of some defected biological
mechanism, I would fall victim once again to another episode.

It took me years to finally understand that that's an oversimplification of a
highly complex illness. The chemical irregularities that characterize
depression are influenced more so by emotional stresses and the interaction of
an individual within the social environment, than say, genetics (it can
increase the probability of development, but it needs to be "activated" by the
environment). I think the best way to approach depression would be to identify
and understand the condition not in isolation, but contextually as a coping
mechanism to the stresses surrounding us.

------
PaulHoule
Just like cancer is caused by environmental pollutants, depression is caused
by toxic social environments. You learn to be helpless. Shine light there and
research funding goes bye bye.

~~~
imd23
Wow. "depression is caused by toxic social environments." you have no idea how
you just helped me there. :)

------
visarga
By the way, chemotherapy can cause depression. It's not the "normal"
depression associated with the realization that one has cancer, but a deeper
depression with a separate cause. It seems people who undergo chemo lose the
ability to create new neurons in the hippocampus. The hippocampus is the only
place in the brain where new neurons are born throughout our life. Losing the
ability to create these cells is causing depression.

------
jdpigeon
I disagree that "depression is as biological as cancer and heart disease" due
to the fact of etiology. While it does spring up out of the blue in many
cases, for the most part depression appears to be triggered by complex life
circumstances. That is not say that it is not a real disease state with a
discrete biological basis. It should just be kept in mind that often the most
salient things involved in getting someone depressed and getting them out of
depression are not biomedical.

It's possible that this is a mostly rhetorical statement by the NIMH head, but
I've been disappointed the attitude I see a lot of researchers take towards
depression, like it's solely the result of bad gene expression or bad brain
connectivity.

------
noam87
On the question of whether "mental illnesses" are diseases or simply arise
from behaviour (as discussed in comments below).

My personal theory is that they are neither. Most mental illnesses are
actually social illnesses. That is: we've engineered a society that is hostile
to a set of (perfectly healthy) behavioural phenotypes.

It's already known that within different cultures and environments, those with
certain "mental illnesses" fare better or worse.

Nobody with cancer "thrives" depending on their cultural environment, but if
you're an engineer on the Autistic spectrum, you might. If you're an artist
with ADHD, you thrive. Even schizophrenics do well in some cultural
environments.

Force someone who was born bipolar, or with attention deficit in a society
that demands them to sit in an office (or classroom) for 8-10 hours a day,
every day, at the same time, and focus on the same thing, and sure... they
will become "disordered". Just as most people would go crazy in the sort of
fluid or even chaotic environment that those people would thrive in.

* * *

A Thought Experiment:

Imagine you were born into a world where the predominant behavioural phenotype
is bipolar or ADHD: there are no set work hours, only goal posts. Teams work
in frenzies of 24 - 36 sleepless hours, followed by a day or two off. Maybe
one week there's no work, but then for a month it's crunch time. Some days you
work nights, some days you work early in the morning. Everyone wears many
hats, otherwise they'd become bored; and you're expected to do the same.

To everyone, this is just the way things are. To you... your stress levels are
through the roof, you can't focus in such an environment, yet everyone is
wondering what's this guy's problem? Why does he have such a hard time working
in a fluid environment? Why does he need special treatment and be given
evenly-distributed work at predictable hours?

Clearly there's some sort of disorder going on here. So you read some
pamphlets and you see a Doctor... maybe there _is_ something wrong with you,
you think. It's so natural for everyone else, yet you can barely function in
society. Luckily for you, there is "help": the standard treatment for Rigid
Thought Pattern Disorder is a 50mc dose of LSD every three days. Sure, it
makes you not quite feel like yourself, but look at how much you've been
improving since you started treatment! You no longer sleep regular hours like
you used to, you're no longer displaying Rigid Thought Patterns. Just give the
treatment some time and you'll get used to the side effects.

* * *

I have no science to back this up of course. Just something I think about
sometimes at 3 in the morning while I'm having a particularly productive
night...

(Yes it's likely that this would be a rather inefficient world in many ways,
so it makes sense for the predominant behavioural phenotype to be more
predictable and stable. The point being, in both cases the non-neurotypical
individual can have a positive impact if they're not regarded as deficient,
but if instead we see these differences in behaviour the same way we see
differences in height, strength, or any other physical attribute.)

~~~
dfc
It is strange to me that you never mentioned how depression fits into your pet
theory of mental illness. Can you enlighten us and explain in what type of
cultural environment someone with depression thrives?

~~~
noam87
Is the depression inherent to the disorder, or is it caused by the unrelenting
stress brought on by living in an environment that is actively hostile to this
individual?

Either way, it's just something to consider based on personal
observation/experience. It could be completely wrong, could be a bit of both.
There's no harm in asking questions.

* * *

edit: to you comment below. I am suggesting that the depression itself (for
example, in the case of a bipolar individual -- not in the case of major
depression, which is a different thing altogether), could be a symptom not of
a "disease" but rather a natural reaction to living in an environment that is
toxic to him or her.

In such an environment, it is perfectly natural for this individual to lose
all drive, feel "worthless", and even break down mentally.

The links between chronic stress and depression are well known. Robert
Sapolsky has a great lecture on the biology of depression:
[https://youtu.be/NOAgplgTxfc](https://youtu.be/NOAgplgTxfc)

(tl;dw: major depression physiologically looks very little like "sadness" and
a hell of a lot like chronic stress (an over-active stress response) and does
indeed fit the profile of a biological disease, often caused by early trauma.

My question here is: have we built societies that are inherently traumatizing
to individuals with particular behavioral phenotypes? Looking elsewhere, at
societies and subcultures where these "disorders" are not as common or as
debilitating to me suggests that there is at least some truth to this.)

~~~
dfc
That is your description of a cultural environment where someone with
depression thrives? It kind of seems like you dodged the question. I am
interested to hear how someone can thrive when they cant manage to get out of
bed.

------
igravious
> The problem stems — yet again — from the disorder's fuzzy definition:
> grouping everyone with a diagnosis of major depressive disorder into one
> genetic study is like looking for the genetic risk factors for fever,
> explains Flint. “You would have lumped together autoimmune disease,
> infection, cancer and a whole set of different conditions.”

This is quite the problem, yes.

But ultimately the perceived intractability and the root cause of the
difficulty of investigating this phenomenon is the subjective nature of the
reports of the symptoms. Clearly _something_ is up, we can see that from
macro-behavioural patterns and cases of attempted suicide -- but these
diagnostics are crude.

What is needed are robust bullet-proof objective diagnostics[1][2]. It's great
that we've progressed beyond "humours" and "hysterics" and "demons" but
compared to other areas of modern medical research we are practically in the
stone ages as the article points out.

For instance: we could have genetic, bio-chemical, neuro-chemical, and/or
neuro-wiring diagnostics. Any others? Until there is a comprehensive set of
biological markers scientists are of course going to be reluctant to research
this. It's unfortunate but I can't say I blame them.

And what if the majority of major depressive disorders turn out to be down to
wiring? And what about the perfectly natural reactive depression one gets when
someone close to you dies or when a relationship breaks up and you lose your
partner and/or your kids. Are we now saying that we oughtn't feel this way?
And what if the way we've structured society plays a large role in our
individual well-being and wellness, what then? What if it turns out to be part
of the human condition, as is perhaps the case with existential depression[3]?

Absolutely the best book I've read on depression and suicide is _Night Falls
Fast_ [4] by Kay Redfield Jamision, a Johns Hopkins psychiatry professor. It's
a few years old now but I don't think that the topics and themes in it will
ever date even though the science in it might. It is filled with compassion,
it strives for precision. I cannot recommend this book highly enough.

Welcome your thoughts on the matter.

[1]
[https://www.ncbi.nlm.nih.gov/pubmed/19396703](https://www.ncbi.nlm.nih.gov/pubmed/19396703)

[2] [http://www.newsweek.com/first-blood-test-depression-holds-
pr...](http://www.newsweek.com/first-blood-test-depression-holds-promise-
objective-diagnosis-270951)

[3]
[http://www.davidsongifted.org/db/Articles_id_10554.aspx](http://www.davidsongifted.org/db/Articles_id_10554.aspx)

[4] [https://www.nytimes.com/books/first/j/jamison-
night.html](https://www.nytimes.com/books/first/j/jamison-night.html)

~~~
ribasushi
> Absolutely the best book I've read on depression and suicide is Night Falls
> Fast ... I cannot recommend this book highly enough.

Honest question: do you recommend the book to folks suffering from non-trivial
depression? As in: is there some sort of "happy ending" within the precise
facts it lays out? Asking for a friend...

~~~
igravious
Sorry for taking so long to reply. I didn't know how best to answer you.

I do recommend it but not it alone. The books points to scientific studies of
depression. A constant theme is nature versus nurture but always from the
perspective of scientific studies, twin studies, demographic studies. What
makes this book different though is that it contains short biographies of
people who have taken their own lives which grounds the surrounding discussion
in the human element. It looks at the history and current practise of dealing
with mental health issues and shows us the barbarity and futility of many of
the practises. It debunks myths. It evaluates theories dispassionately while
at the same time having compassion for the sufferer. It's a beautifully
written book. There is no "happy ending". But that's not the point, the point
is to gain a better understanding of this huge social and personal phenomenon.

Hope that helps.

------
amelius
> genetic studies have come up empty-handed

Perhaps we should focus more on data with a hereditary component (?) This
would eliminate depressions that are really sadness caused by life events.

Also, I wonder if clustering techniques have been tried to the fullest in
separating genetic data.

