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There is little research into the long-term effects of using antidepressants (theguardian.com)
201 points by DiabloD3 on May 8, 2017 | hide | past | favorite | 156 comments

I was also put on antidepressants as a teenager and am trying to get off them after well over a decade. It's a tricky task to distinguish the withdrawal effects (which can be extreme) from the difficult emotions that come with rediscovering how to face the world without the drugs. It really feels like a part of my personality was frozen in time when I went on the drugs, and that as I come off them slowly that part of me has thawed. And that can be painful, but also extremely rewarding. It forced me to acknowledge truths about myself that I resisted for many years. It forced me to be more real with people in my life. It's the realization that I was depressed for actual emotional reasons and not just because of some putative neurochemical imbalance, the idea of which in such huge numbers makes absolutely no evolutionary sense. A trait this common is not a disorder---it's a survival mechanism.

Thanks to everyone for their heartfelt responses and interesting viewpoints! Some have pushed back regarding the notion of serotonin imbalance. I would point you to literature that strongly challenges the idea of straightforward neurochemical imbalance as the cause of depression. This is a good place to start: http://kellybroganmd.com/depression-serotonin/

From that article:

> "The most applicable analogy is that of the woman with social phobia who finds that drinking two cocktails eases her symptoms. One could imagine, how, in a 6 week randomized trial, this “treatment” could be found efficacious and recommended for daily use and even prevention of symptoms. How her withdrawal symptoms after 10 years of daily compliance could lead those around her to believe that she “needed” the alcohol to correct an imbalance. This analogy is all too close to the truth."

I believed in the chemical imbalance theory for many years, but now I am persuaded that it's more marketing slogan than scientific reality. This is not to say that antidepressants cannot have beneficial effects. Just that it's not clear that they are correcting any naturally occurring imbalance.

As far as the interesting point that emotions and neurochemical brain states may be equivalent, I grant that this may be true. I guess it was more my way of referring to two approaches to emotional problems: the first, which sees the problems originating in the brain chemistry, internalizing the dysfunction within the sufferer. The second, which sees the brain chemistry mostly as a reaction to the life and environment of the sufferer, wherein the true dysfunction lies. This points people in the direction of their relationships, the congruence of their values and choices, their life philosophy, etc. which I find a more productive pursuit.

I hope you realize that Kelly Brogan is a complete quack. She posts all sorts of feel-good nonsense memes on Facebook without a shred of scientific evidence. For example:

"Saying no to pharmaceuticals is an act of feminism. Every time you open that pill bottle, you are saying 'nope you don't got this' to your body, and you are instilling a message of oppression by a system that says feeling anything is dangerous."

From where I stand, that's a powerful quote. Your calling that person "a complete quack" based on the quote alone comes off as ideologically narrow minded to me.

Some seem to think that "science based medicine" is incompatible with approaches centered directly at the level of belief and doubt, yet large numbers of doctors regularly prescribe placebos[1,2], some even using things like antibiotics or steroids for this purpose. Perspectives that cultivate positive, empowered spiritual and mental outlooks about one's ability to heal and live well are not "quackery".

Am I against scientific approaches to healing? Not at all. I'm against unfounded allegiance to mediocre, dogmatic forms of "science" that default to shunning any perspective outside of their scope of understanding.

Thankfully, there are open minded doctors and scientists out here shedding crusty dogmas. e.g. http://news.wisc.edu/study-reveals-gene-expression-changes-w...






It's a shame that this moderately spoken, and well documented counter to the OP's ad hominem attack on the author of the linked article is downvoted so heavily. I appreciate HN's love for science and disciplined understanding of the world, but disappointed by the lack of open-mindedness towards beliefs and perspectives that aren't peer reviewed or approved.

Keep in mind every community is a hive-mind that gravitates to the mean.

Hacker news is good for intelligent discussion, but when the topic is on something that isn't empirically measure-able (IE: mental health in this scenario) conversation goes downhill pretty quickly. I'm quite concerned about how the majority are medicating so quickly, early and in a way that's mostly unchallenged.

I mean we barely understand the I/O of the brain, yet we're claiming some pretty heavy positive bias on chemical remediation. It's a pretty farked situation, being unable to talk about it in a neutral environment frustrates me to no end. The top comment on this thread though, perfectly sums up my perspective on depression:

"It's the realization that I was depressed for actual emotional reasons and not just because of some putative neurochemical imbalance, the idea of which in such huge numbers makes absolutely no evolutionary sense. A trait this common is not a disorder---it's a survival mechanism."

I want to understand depression, it's just such a hard issue to tackle scientifically. The scientific method takes the subject out of the equation, nuking any sort of bias. But that doesn't work when the issue that needs to be understood IS the subject.

I need data, subjective perspective from all walks of life is the best dataset I think I can use to shape my understanding. I want to talk about depression from a neutral, logical, mindful and philosophical perspective. Maybe then I might understand where, why and how medication would or should come into play.

In absence of any valid science what criteria should used to sort out BS from "the good stuff"?

It's a good question -- the way I look at it is that science is the realm of the things we understand using our mathematical representation of natural phenomena (eg. physics, etc). However, it would be foolish to believe that this set of knowledge represents entire understanding of the universe. Thus, given the premise that there is a large (probably near infinite) set of things we don't know outside of our current understanding, I try to keep an open mind towards things that seem estoeric or unfounded.

But how to distinguish this from absolute nonsense? Intuition is probably the number one thing -- what smells like BS? It's not a perfect substitute for objective knowledge, but I think as engineers and scientists, we undervalue our subjective life experiences in shaping our view. Also, it helps to have a discerning eye for the macroscopic message the author is trying to deliver. Many times, we tend to attack the articulation or delivery of a thought, and miss the underlying message. In the context of the author of that article was saying, we can all agree that we have a poor understanding of pharmaceuticals (SSRI's in particular), and it helps to stay with the feeling of depression to know what your body is trying to convey to you, rather than flood the body with more input to make the "negative" emotion leave. I took that thought and discarded all the other specifics -- because I don't expect anyone to be 100% right, and hence I take the kernel in each viewpoint and leave the husk.

I was a little worried linking there since I can't vouch for the rest of her output. But that particular article seems solid to me.

This anti-establishment part of psychiatry certainly attracts fringe views. But I find the core criticisms of neurochemical imbalances and psych drugs to be convincing.

I think it's important to distinguish the hardcore anti-pharmaceutical attitude from the more reasonable position that, while someone may perform better while taking a medication in some measurable aspects, it may nonetheless be ideal to leave people unmedicated if they would not otherwise be destitute. We may thus model the medicated state as a local maximum but perhaps not the desired result (in particular, we have chosen to err on the more familiar side of the state-space). Conversely, I would have a hard time arguing against, if someone found that moderate regular alcohol consumption had a curative effect on a severe problem, their choosing to continue it.

Exactly. There's no doubt that _some_ people (myself included) became much more functional on SSRIs. But we've got the crutches-metaphor and the insulin-metaphor, and we've swung too far to the biochemical side - because it's easier and cheaper.

I have no idea who Kelly Brogan is and would not be especially receptive to crossing these particularly ideological streams the way they have, but the logic they're employing here isn't that dissimilar from the logic underpinning Cognitive Behavioral Therapy, which has been subjected to serious testing.

Click the provided link, though. It's bad.

The biggest warning sign is that it pitches a serotonin-deficiency model as standard and claims mainstream doctors are "breaking ranks" to oppose it. That's absurd. Knowledgeable doctors don't claim serotonin deficiency causes depression, only that SSRIs can help address depression. The serotonin-deficit hypothesis was advanced because SSRIs treated depression, and discarded when depressed patients proved not to have lowered serotonin levels. Brogan is pretending serotonin deficiency is a crumbling conspiracy, when it's actually a tested-and-discarded hypothesis.

I don't especially object to the pull quote about alcoholism. It's a standard clinical observation that antidepressants don't treat simple serotonin shortages, and work equally well on 'clinical' depression and 'normal' depression like the loss of a loved one. I just object to implying that this isn't commonly recognized.

Thanks for saving me the work of a full three-paragraph screed with your measured, very readable statement of this point.

How are you reaching that conclusion? The unsupported and unscientific assertions made by Dr. Brogan have no relation to evidence-based medicine techniques such as CBT.

I am only responding to that one quoted paragraph. I am not claiming that it is scientifically rigorous, but if you told me that was a pop-sci writeup of ideas based in CBT, I would not be surprised.

This is exactly why I've been trying to get my step-daughter off of the meds. She is on the autism spectrum, and her previous guardian solved behavior problems by pushing more and more meds. We've weaned her off of the anti-psychotic and in the process of weaning her off of the anti-anxiety. We'll see if we can do the same for the vyvanse or adderall.

I have worked with a lot of intense emotions and pain within myself. I have faced them in life and in meditative, psychedelic, and dream states. There are not a lot of darkness and intense emotions that faze me much anymore -- though it isn't as if I've become invulnerable to emotions. If anything, I've become to be more sensitive to emotions, and being OK with that vulnerability. Whatever the emotional state or the narrative, the way it dissolves generally remains the same.

In all the things I have tried, the key ingredient has always been mindfulness. I have found that surfacing up deeply-buried emotions don't do much if one becomes mindless and intoxicated by those emotions. At the same time, I have also tried suppression and repression. Numbing oneself or cutting oneself off from the emotions at best, defers the emotional work you end up doing. Instead, it usually causes more damage.

Mood-altering drugs can help _if_ they are taken along with therapy that necessarily includes mindfulness. The therapy helps change and shift deeply-held beliefs, and it is the mindfulness that lets one unwind the damage from root cause. The drugs in question can help if they support such a process, to be able to help face the scary things within you. If they are taken as a way to _avoid_ this kind of work, yeah, I too also hear they can freeze you at that emotional maturity level.

I can't speak much for depression, but there's a huge amount of research that cognitive behavioral therapy is almost useless for other illnesses (namely ADHD-families). Inversely, medication is _very_ effective for ADHD (assuming this is what the adderall is for, given its comorbidity for a bunch of other stuff).

While I can respect the person themselves making the decision to try and wean off these treatments, taking them away from a child who might not understand the implications is fraught.

I was "convinced away" from ADHD meds in high school, and I had a lot of issues in college + work before getting proper treatment again. Suddenly so many anxiety-inducing behaviors were under my control again.

I would love for CBT to be effective, because the meds do change me, but I've tried it, and there's been research showing it's ineffective.

Inversely, the research shows that ADHD medication treatment is super effective at reducing symptoms, even outright eliminating them for a good subset of patients! It's the most well-treatable mental illness known to science (more-so than depression, even).

Taking away this medication from someone else is like taking away someone's glasses or crutches. At least get their consent, please don't force it on them. And always offer them the option to get back on treatment if they're uncomfortable.

Fair enough, thanks for sharing. I have a good friend who has ADD and is of a similar opinion as you. He has strong libertarian leanings and I asked him how does he reconcile his political philosophy with his use of ADD medication. He told me he considers it as getting him to the same starting line as everyone else.

My own experiences with therapy relate more with meditation and concentration exercises rather than CBT (I kinda doubt CBT works for ADD and ADHD, though I'm not basing that opinion on science). I don't know to what extent meditation and concentration exercises helps with ADD though there are books written about it, and I have talked with at least one person who has ADD and has been practicing it for a while (but I didn't get a chance to ask him how well it works).

I know that for myself, someone who does not have ADD or ADHD, the only way to increase control over attention and awareness is mindfulness and concentration. I am also speaking about "concentration exercises" in the classical sense, such as the term "jhana" from India. That is to say, when I am talking about concentration, I am talking about relaxed (rather than forced), one-pointed focus on one concentration object sustained over long periods of time, rather than the conflated sense of "concentration" when speaking casually about it or in the context of academics or work productively. The mindfulness is related to regaining impulse control by being aware of impulses that flow through the mind.

The other thing to consider is: Autists tend to be given ADD or ADHD meds, but no one really knows if they actually work for the root cause, because we don't really know the root cause for ASD. The closest neuroscience has to offer as a theory is something called Intense World Theory on Autism. All the other theories on Autism are based on behavioral markers rather than neuroscience. An Autist might _present_ as ADD or ADHD, but they are not quite like that.

So here, sample size of 1 opinion: my wife has ADD and my daughter is on the Autism spectrum. They both get distracted. My sense of how and what distracts them when observing them and talking with them tells me it might look the same, but it isn't. It's something our family counselor has noted too, having worked with other people on the autism spectrum or with ADD

As such, ADD and ADHD meds affects someone on the Autism spectrum differently, and depending on physical development.

>I have a good friend who has ADD and is of a similar opinion as you. He has strong libertarian leanings and I asked him how does he reconcile his political philosophy with his use of ADD medication.

What an odd thing to ask. Libertarians aren't 7th Day Adventists. Why would there be a conflict between Libertarianism and medication?

It's not a conflict between Libertarianism and medication. It's a question of the role medical technologies (or any technologies) in opportunity and liberty.

If we come from the frame that certain mental conditions are neuro-chemically-based, and that these conditions prevent someone from being able to be productive members of society, medication might be seen akin to the freedom to participate in a market economy.

When I asked my friend that, I was probing for underlying narratives. From my perspective, there seems to be a heroic element to libertarian narratives, one in which medication like this seem to cheat.

I don't know where you're getting that. Even in the case where the drug provides a big advantage to perfectly healthy people the libertarian position is going to be "society has no business dictating what you put in your body".

Yeah, it's pretty interesting how many ADD/ADHD meds have completely different effects for those with or without the disorder.

As I've read more into this, I've found that "better" indicators of the disorder is more around impulsive behavior (lack of concentration being such a difficult thing to quantify, nobody's concentrated!). Dr Charles Barkley [0] has a decent amount of talks on youtube about this misnaming (and other aspects like hereditary natures).

Depending on where along the ASD spectrum your daughter might be, this might be harder to figure out though. I can understand being a bit skeptical about this.

I hope you can work out what's best for your daughter (and hopefully keep her engaged and aware of what's out there).

[0]: https://www.youtube.com/watch?v=wg6cfsnmqyg&index=2&list=PLz...

Cool, I'll check out those resources. Thanks.

Adderall and vyvanse are a lot different in my experience than anti anxiety and anti depressants. The anxiety and depression seemed to be caused by my environment. Now that I have a happy family and a well paying job that I love anxiety is rare and I'm not depressed.

I tried going completely off the Adderall completely and was miserable. I found myself not completing goals, and having a really hard time doing any sort of long term planning for about six months. I now take an extremely low dose which is consciously barely perceptible but helps me immensely.

Obviously everyone is different but I don't think I could work as a software engineer without 5-10mg of adderall on weekdays.

Keep in mind, adderall and vyvanse work different for someone on ASD than someone with ADD.

My daughter, who is on the spectrum, has trouble completing goals and having a hard time doing any sort of long-term planning on vyvanse ... even for the things she is highly-motivated to work on. She is currently on 15mg of Adderall.

I am only now just teaching her how to organize and plan. It required building a lot of more fundamental skills first: unwinding the entitlement attitude (that seems common in this current generation), getting her used to checking a list of tasks, day by day, teaching her how to use her visualization skills for both planning and for shaping and solidifying intent. (She is very good at visualization. She doesn't use her skill wisely). We're now just getting her working with a planner and weaning her off of direct supervision.

Today was the first day she woke up on her own with the alarm clock. This was months in building her to this point since she first started living with my wife and I during the custody transitional phase. My daughter had somehow trained her brain to ignore the alarm clock with her previous guardian, and the entrenched entitlement attitude did not help. We have had to do a lot to get to this point. The final bit was, in each of the past three nights, I had her visualize (using both sight and auditory modalities) the clock turning to 7:15, hearing the exact sound, and then seeing herself get up. Last night, I introduced to her "intent" and how to shape and form an intention to get up. (And man, I wished I had someone teach me how to shape and focus intent when I was a kid... not that I would have been in the right mindset to take that in back then). Will there be a regression? Likely. Stuff like this takes time and persistence.

This milestone is still one step in many. My intention is to teach her how to use her mind and how to use it well. If we wean her off of Adderall, it would come after a lot of intense, ongoing coaching on how to shape and solidify intent, how to use visualization to accomplish what she chooses rather than to sabotage herself, how to organize, how to reason, and a solid basis for morality, ethics, and values. The hardest part will be learning how come into focus and gather will without the use of a consciousness-modifying substance.

Slightly off topic, but this methodology seems very interesting. Curious could you share any relevant literature?

It comes from a number of sources, both words you can read and experiential things. These were studied, experimented with (on myself), and practiced over the course of the last fifteen years. I have never attempted to synthesize what I am trying into a coherent whole, and I am still learning and assimilating other methods.

Neuro-linguistic programming is probably a good place to start. That's where you get ideas such as sensory modality, reframing, etc. I mostly went through a couple books transcribing John Grinder and Richard Bandler's workshops in my twenties. Grinder and Blander mentions Virginia Satir and Milton Erickson a lot. Grinder and Bandler was where I first learn to "chunk down" skills and ideas (in software engineering terms: to decompose a skill into micro-skills). NLP is where I also learned how to construct (and deconstruct) visualization exercises.

Other methods along these lines are Suzuette Haden Elgin's "Gentle Art of Verbal Self Defense", which has a lot of patterns and anti-patterns on use of words. I have read through Jay Heinrich's "Thank You For Arguing", which is the book I credited for making the distinction between being right and being persuasive for me. (Can't wait to start teaching my daughter Heinrich's material).

The most recent, more mainstream book I am working through is "Take Back Your Kids" by William J. Doherty. My wife found a condensed, one-page essay by Doherty on respect and community building and I started deep diving into his book. This one is important since my wife and I concluded that part of the issue with my daughter is that entitlement attitude was conflated and intertwined with the issues with the autism syndromes. We had already gone through the Intense World Theory, so we had a good feel for what was likely to be autism related ... and what was more likely to be entitlement.

The rest of this comes from experiential sources. There are good literature to start one off, but reading it alone will not lead to understanding. Experiencing it will.

The shaping and solidifying of intent comes from several sources converging together. Internal martial arts has a lot to say and practice about the shaping of intent. In particular: xingyiquan emphasizes when intent clashes together; taijiquan emphasizes the relationship and the give-and-take of intent between two people; and baguazhang emphasizes the changes that take place within a person as a result of changes in the environment (and how intent plays, shapes, and is shaped by the environment). I have not even begun to scratch the surface of these arts. I've touched it just enough to know, there are some broad and deep healing applications when it comes to people.

Shamanic practices has a lot to say and practice about the shaping of intent as well.

Mindfulness practices lets you get a sense of ebbs and flows of sensations, emotions, and thoughts. It is entering that stillness and emptiness that lets me try all these different techniques, and to observe what is going on.

One interesting phenomena happens after becoming sufficiently mindful: you become aware that some of the shifts and changes in your own emotions and thoughts are actually mirrored in the other person. It becomes hard to say whether it is "your" thought or the "other person's" thoughts.

This perspective has been very useful when working with my daughter. At first, it was hard not to get caught up in what she is thinking. After a while, I started recognizing when she was getting in stuck patterns, loops; whether because she was drawing a complete blank, or because what I said was too ambiguous for her, leading her to fan-out into many possibilities. I can also tell when she "skips" steps in her thoughts, and because it happens so fast for her, it doesn't even register as a conscious thought for her (this is the part that a lot of people mistake as an expression of ADD).

Right now, my daughter controls her mind like the way an overeager and anxious teenager drives a car. She doesn't know how to adjust the accelerator and brakes, doesn't know what "enough" means. All she knows is to push things to the metal. Asking her to remember and to introspect on specific thoughts and feelings is like asking her to park the car at one specific parking spot in a busy parking lot. Without the ability to adjust how much to push on the accelerator or to break, it is hard to refine movement of the car and get it into the parking space. You're going to run over a lot of things. Likewise, when she retrieves information, when she processes emotions, when she tries to reason through things, she slams on the accelerator or slams on the breaks. She jerks her mental steering wheel and then overcompensates when trying to correct it. (And she does that physically with her bike; it took practice before she started to figure out how to gently squeeze on the breaks to control speed). She has a powerful mind, but lack control and wisdom.

It's my belief that this skill is learnable and trainable. I did the same with my own thoughts and intent, and it took practice to work with it more gently and more subtly. It requires a sufficient level of concentration and mindfulness. It requires knowing how much is enough intent, and to watch for the results that comes from expressing or executing that intent.

Hope that helps.

Appreciate taking the time. That's fascinating, thank you.

Those are mighty strong assertions from someone with a sample size of 1.

Feel free to ignore it.

Personal experience isn't Science, but it is a powerful influence on one's beliefs.

I'm okay with that. I do hear you that it shouldn't be generalised to a broader experience.

Thank you!

This really hits home for me. It's exactly how i've feel but always get ridiculed for because of the sheer number of people who are prescribed it and that it works for them so I must be wrong.

I don't doubt that some people really do need it, but I was not one of them (I didn't respond well to them) and I have a hard time believing so much of the population actually needs them too.

But if anything, better solutions / alternatives need to be presented and made available before people are just thrown off something that has helped them handle some really tough stuff. But the problem with that is, then the drug companies wouldn't make so much money. (which, I think plays a large part of it)

It's not just that - it's that from a perspective of a psychiatrist there is no safer drug to get someone out of a deep hole.

The thing is that people should be trying to figure out what was the underlying issue and whether it's possible to fix it. Not many doctors have the motivation to do this infortunately, and many patients don't either.

I've met people with adhd and daytime sleepiness, who spent years on antidepressants. The effect was that they still couldn't focus, but didn't feel depressed because of that, and didn't even know they had problem.

My own personal opinion is that modern society is more crazy than most patients. This is likely the root cause of over-prescribing drugs. Yes people are in need of changes in their life to feel better, but the solution should be for society to suck less, not some pill to mask the symptoms in individuals.

Note that anti-depressants—at least in the case of episodic depression—are supposed to be used as a crutch, not as a "management therapy." You prescribe anti-depressants to someone who can't get out of bed to see a therapist, so that they will then get out of bed to see a therapist, where the therapist can then get them over their depression. Anti-depressants are not supposed to be used "mask pain" any more than crutches are supposed to be used to "mask pain" in your leg. They're supposed to take the pressure off a thing that generates pain, so that you can work productively on making your life better (healing the leg) so that you don't need the crutch.

Though, that being said, there's also a second, less obvious thing anti-depressants do: first-line anti-depressants specifically are hard to distinguish from placebos, but that's okay because first-line antidepressants are often prescribed by doctors who believe† that a placebo is, in fact, all a person might need in order to feel better. That's why they're given out so freely: placebos are pure benefit (no risks, possible reward) so it doesn't hurt to try them before doing literally anything else.

If the person doesn't improve under first-line placebos, then the doctor will move on to figuring out what "actual" medical interventions might help.

† This approach is doctrine among psychologists, but not necessarily what your average psychiatrist/therapist/prescribing GP will be thinking about. Prescribers "out in the field" are mostly following the DSM guidelines for first-line/second-line/Nth-line treatments of depression, which just say that the first-line pharmaceutical interventions are very well-tolerated and low-risk.

I can see how you were probably trying to say that these medications are supposed to be used to empower the kind of changes you thought I was talking about.

However, I'm actually talking about society in general being depressive. About it being difficult to socialize because of distance, economic/social divides (real or imagined), the time spent at work (duration and even sometimes just the conflict) or because transportion is so bad/costly. There are also those who are stuck in some rural/suburban desert of contact and opportunity.

My ultimate point is that the /depression/ might actually exist for valid reasons. That in a pre-modern society this feeling could be a survival trait in driving an individual to leave a bad or over-populated area for new/different grounds. However modern society has closed off these historic reactions and has not replaced them with modern equivalents. Thus the subjects experience learned helplessness, as there isn't any way out and they thus give up on looking for or taking opportunities to have a way out.

This same lack of a visible, viable, and valued escape trajectory can also explain other contexts where subjects act against the rational interests of themselves and the communities that they seek to remain part of. For example, when I was describing the above class of scenario victims of abuse from those close to them (parents/spouses/etc) come to mind.

Of course depression exists for valid reasons (I've heard good evo-psych explanations concerning adaptations to signal guilt in response to belief that one has been exiled from a tribe, etc.)

But it's also an extremely maladaptive state to be in—no matter the environment—and one we'd best force ourselves out of, even if doing so is "unnatural." There is just nothing good that comes—ever—from a major depressive episode. It makes it harder to gather the energy to do anything about whatever is causing the depression. It's a positive feedback loop.

Note that I agree with you fully that dissatisfaction or sadness or ennui or whatever else, is a perfectly valid—and useful(!)—response to being in a bad environment, one that drives people to change their life for the better.

But depression is not any of those things. Depression is—as the pharma industry explicitly defines it—the feeling lab rats get when they've struggled to get out of water for so long that they just can't stand struggling any more, and give up and float. (https://en.wikipedia.org/wiki/Behavioural_despair_test)

That state—helpless despair—is the thing that impairs feelings like sadness or ennui from motivating you to change your environment. Anti-depressants are targeted specifically at counteracting that feeling, so that negative emotions will be re-connected to motivation.

(Note that this is why anti-depressants always carry risks of suicide: suicide is one form of escape from negative feelings, and people suddenly motivated to do something to escape from negative feelings will have suicide suddenly pop into their heads as a strategy for doing so. Whether they consider it a valid strategy is up to the person's particular psychology, but they'll be itching to do something. I would guess that it's more likely they'll choose that option, the fewer other options they have.)

@derefr, @mjevans I agree with you both.

It's my personal opinion that these meds are better used as a crutch to help someone seek out therapy. I've seen people get trapped in their own psyche where, they are running in a closed maze of suffering, unable to find their way out of it.

I also think modern society is bat-shit crazy. It isn't just that depression has been dismissed as a survival trait, or even that it is demonized. There are aspects of modern society that induces much greater existential anguish which is then cleverly swept under the rug of "Progress".

Thank you for helping me see another way that Derefr may have mistaken my sub-topic. I can now see that I needed additional emphasis on "depression" and "sadness" being used interchangeably in modern conversation, and how treating the issues of both is complicated by the focus on just making a problem go away rather than identifying the true nature and causes of that problem.

People, doctors who should know better, and patients who should be better informed by (and listen to, and have //repeated// re-education by health professionals as the corrective actions enable them to think more clearly), will and do abuse the "crutch" as a "magic pill to make the problems go away". The for-profit nature of healthcare within the US also leads to a lack of appropriate balance in treatment and an over-reliance on pills.

I do not disagree that depression can be an irregularity within someone's body, but I am trying to convey that //sometimes// (unknown quantity, who even studies that?) the source of the problem is ultimately outside of the individual's body, and therefore the ultimate solution is also there. I worry that the reason people are loosing sight of "their true self" is that what should be a "crutch" has instead become a permanent mask that they wear as their only identity.

Modern medicine works by identifying symptoms and treating symptoms, far less often even identifying the underlying root cause(s), let alone treating them. This is great if the symptom is acute like a stabbing, gunshot, or heart attack. It's less so if the symptom is environmental.

Was pre-modern society with all of its superstition and interpersonal violence less crazy than modern society?

I think interpersonal relationships are a lot more complicated today. We're supposed to be oh so civilized and well adapted, while lugging around a legacy as apex predators. Basically gorillas in suits that have to sit in an office chair all day, and make polite conversation at the coffee machine. Consider that most so-called anxiety can be traced back to the fight-or-flight response, where we are conflicted because we want to either go nuclear or get the fuck out of there, but can do neither because of social pressure and inhibitions. No wonder some people flip.

Despite not having been there, I'm gonna say it probably was.

I'm glad you are feeling better but while some people's problems do come from emotional sources, please don't act like the chemical imbalances in the brains of other people aren't a disorder. I promise you, I and others like me have tried our damndest to "feel better".

OP is not telling you to "feel better" - he is saying he was only able to tackle his depression after taking a more holistic approach to monitoring and changing his brain operation.

Emotions are, quite literally, certain chemical states in animals with nervous systems of at least a certain complexity. That's where the "chemical imbalance" mantra falls apart - at best, it adds no information, and even worse, its used to peddle drugs which are developed without coherent and predictable models of the neurology involved in the symptoms/diseases they're supposed to treat.

Medical doctors get at least one objective measure of your blood pressure before prescribing blood pressure medicine. When was the least time you heard of a psychiatrist only prescribing meds after performing an MRI?

What new information would current state fMRI give them?

If I'm not mistaken, a person that is depressed due to environment will have similar fMRI as a person who has messed up biology (not just neurotransmitters btw).

Also, even with acute depression, antidepressants may help to get the patient on track.


The objective outcomes differ with different treatments even in cases of subjective success. The specific neurology (protein levels, chemical ratios, etc) should determine how exactly you intend to alter it.

Psychiatrists (well, ER doctors, usually) do, in fact, perform MRI's before prescribing meds. This happened to me when I was first diagnosed with bipolar disorder, and I assumed it's not an uncommon practice.

It's easy to think of psychiatry being wishy-washy when all you're considering is mild to moderate depression and the like, but it becomes much harder when you consider the entire spectrum of mental illness. Full-blown mania, psychotic depression, or untreated schizophrenia scream illness in a way that is hardly subjective.

This isn't like a reprimand or anything, just to point out that this problem cuts both ways. Having been entangled with the mental health system for 20 years, I say the lion's share of attention and advice, from everywhere and everybody, comes from the chemical imbalance / illness / disorder perspective. And this really, really does leave those of us who don't respond to drugs and are fundamentally unhappy with our lives very frustrated and without anywhere to turn. Yeah, therapy's a thing, but it's commonly perfunctory and treated as secondary. Treating depression like it's just one thing can harm sufferers on both "sides".

A big reason drugs are preferred to therapy is that the drugs are far cheaper. 6 months of antidepressants can be like $80, 6 months of bi-weekly therapy $5,600.

My understanding is that mental health therapy should be covered by most insurance plans these days so the out-of-pocket shouldn't be that high. While it's a sample size of only one, my wife sees her therapist bi-weekly and I think the co-pay is $20 per session. A month's supply of Duloxetine (generic Cymbalta) actually costs us more per month at $45.

It's incredibly difficult to find a great therapist. There is a fundamental supply and demand imbalance, and plenty of quacks on the supply side.

Not only is therapy expensive, it is non-existent. We live in a decent-sized city and have tried numerous psychologists for our daughter and they all suck. I've decided that outside of psychiatry, as in, someone who is actually an MD, the rest of the field is utterly worthless. And the psychiatrists only want to medicate. Honestly, we've gotten better outcomes from just our family pediatrician.

Not to mention the potential cost of missing work to go to therapy. Some people don't have PTO or a flexible schedule and getting to therapy appointments is a real pain in the ass.

>I promise you, I and others like me have tried our damndest to "feel better".

There is a whole arm of behavioral therapy based on the idea that trying to feel better, is a major cause of people feeling bad.


Of course, it doesn't work for everyone.

Can we really distinguish those two sources? It seems to me that the chemicals and the emotions are the same thing.

The problem, I think, is that sometimes the chemicals come first and other times the emotions come first.

Both can lead to a self-reinforcing downward spiral, but trying to fix the wrong half is likely to be ineffective.

I'm out of my depth here so apologies if I'm stepping into some Very Bad Anatomy but my point is that neither one can come first because they are the same thing, that those chemicals are your emotions and vice versa.

They don't map one to one. There's a thousand variants of emotions, and just a few neurotransmitters.

Also, even with all the chemistry being fine, there can be certain receptors messed up, or parts of brain not functioning properly.

A story I read in "Listening to Prozac" was about a patient that for years couldn't get over his low self esteem issues. He worked through all of them, but the feeling persistent, and there were no other issues with his mood aside from that.

He was finally put on antidepressants, and that issue was fixed. Unfortunately, whenever he tried to get off them, the issue - and only that issue - kept coming back.

The theory is that something made that part of his brain resistant to serotonin. There are many kinds of serotonin receptors, and perhaps a genetic problem messed up one of them. Or there was an issue with serotonin not being delivered where it should've been. Or who knows what.

In the end, increased serotonin levels fixed that. A blunt tool, but no other one worked.

Similarly with attention deficit (which comes with anxiety and sleep issues quite often) - the original theory was that it was due to dopamine issues, because increasing dopamine levels helped most people.

The current theory is that in many cases it may a whole class of issues - from a mechanical damage to prefrontal cortex to allergies, magnesium processing issues, tyrosine processing problems, or even a deficiency in nicotinic receptors (where supplementing nicotine is really a solution!)

Also, in most cases it's probably more than issue at root. The problem is that it's difficult to figure it all out, and many cases medicine is simply not there yet.

> a deficiency in nicotinic receptors (where supplementing nicotine is really a solution!)

My doctor actually recommended nicotine for that exact reason. My family's history with heavy tobacco use combined (my father in particular) and my experiences with nicotine in the past were positive, so the doctor suggested trying a strong nicotine patch for a while. It worked reasonably well, and more importantly it didn't have the (many) problems the usual SNRI or NDRI. Nicotine definitely does have its own problems, but it's an interesting option that deserves more research.

(We had also discussed briefly the idea of trying a very small dose of one of the acetylcholinesterase inhibitors used for Alzheimer's, but eventually decided against it, because they can be somewhat dangerous drugs.)

For decades, research on the nicotinic acetylcholine receptors was limited (probably tanks to the tobacco industry). Research in this area is improving a lot, but it will take time to make up for the lost time.

Wow, that's an amazing doctor.

When I discussed the subject with two psychiatrists, they seemed unaware of how it connects to psychiatric issues.

I'm not quite sure how to respond to this, so I apologies in advance if it comes off wrong.

I would say it's not about trying to "feel better", you can't just force yourself to not feel depressed, the brain is too complex for that. There are, however, many rigorously proven methods for tackling depression that can work in replacement of or in addition to medications. The one I think has the most merit is mindfulness based cognitive behavioral therapy. The idea is to build up a new set of habits, coping skills, and behavior patterns that let you life your life without getting sucked into depression. Depression is vastly more complex than simply "a flaw in brain chemistry", that's very reductive reasoning but it's been a relatively successful one for the psychiatrist business and pharmaceutical industry. That brain chemistry is as much a symptom as it is a cause though. And with enough work it's possible to make yourself more resilient to potentially depressing circumstances and thoughts. It's possible to train yourself to recognize and change the constantly running background narrative of negative self-talk that gets you down, the rumination, the trains of thought that seem so unavoidable, and so on. And then on top of that to build better habits, to tackle your problems, that you're in control of, and prevent them from growing out of control, to regularly exercise, etc.

Of course, it can be difficult if not near impossible to do all that, or, really, anything whatsoever, if you're deeply depressed. Which is why for many people it's necessary to begin anti-depressants before starting therapy, making behavioral/cognitive changes, etc. The problem the parent poster is talking about is the tendency today to just shove people into the top of the process and call that done. It's now expected that most people who have experienced major depression should just take anti-depressants for their entire life and that's the "cure" for their problems. With only a token concern for building up the skills, habits, and coping mechanisms that people actually need. You see the same thing with a lot of other things like ADHD or anxiety, with a tendency to look for the chemical answer first and foremost and call that good enough.

I had a similar experience after ending my 15 years on Concerta/Ritalin. I was so used to feeling "always on," that it warped my worldview. That, to me, was more disconcerting than having to reevaluate my understanding of myself.

I can identify with my medicated self, because I am always in some sort of flux and I accept that ambiguity. I cannot relate to my medicated worldview; I am out of Plato's Cave.

I empathize with your struggles to be chemically independent and to dig deep to confront your truth. Any naysayers just don't and can't understand your path. Without digging to deep, I just want to express my support and a {{{{{{{giant internet hug from a stranger}}}}}}}

> It really feels like a part of my personality was frozen in time when I went on the drugs, and that as I come off them slowly that part of me has thawed.

I'm sure you are talking about antidepressants, but I wonder if the same isn't true for people who have consumed recreational drugs for extended periods. It seems natural that if you regularly alter your internal chemistry, the natural processes that would happen in an unaltered states (such as psychological maturation) would also be altered. I also wonder if there isn't a standardized therapy kind of like PT for physical injuries for bringing people back up to speed emotionally.

It's also possible that antidepressants (and drugs of abuse) numb some part of your mind that's broken due to emotional trauma, and as a result you lose that part of your personality while it heals. Then, when you come off the drug, you're all better. It's like a kind of mental anesthetic. This could explain why many drug abuse problems spontaneously resolve.

I'll admit this sounds kind of insane, but I'll also point out that we still really know so little about the actual workings of our own minds. Maybe we're misunderstanding the relationship between people and psychoactive drugs.

Remember that this is just your experience - just like some people have messed up insulin, some others have serotonin.

It's just that in this case we distinguish genetic issues from environmental.

Just out of curiosity - what would be the adverse effects of being on anti-depressants all your life? Are there any side effects that negatively effect you if you use it in medical doses?

I'll tell you, with 100% conviction, that I would not be alive today without prescription antidepressants and mood stabilizers. Of course there are side effects, and it can take a while to find the right drug or combination of drugs for your particular brain chemistry. In most cases, I've considered the side effects worth the improvement to my life. Even with them, I'm still not completely "normal". These symptoms are with me for the rest of my life barring some amazing medical discovery.

Mental health issues as a whole are difficult to bring up, even to a doctor. I actually worry about writing this on my real account. It's looked down on as if "you just can't handle life" so you "just feel sad". Chemotherapy is also a very unpleasant experience, but I don't think there would be much interest in an article about some imagined overprescription of chemotherapy.

> It's looked down on as if "you just can't handle life" so you "just feel sad".

Loved ones have mental health problems and those reactions just piss me off. If someone has a broken bone sticking out of their leg, nobody questions why they have a hard time walking. If they have a heart attack, nobody questions that they can't go to work today and need medical attention. But when the most powerful, essential organ in the body has a problem - well, just buck up and get over it, which is similar to, 'just buck up and walk off that heart attack'. Or they say, 'I'm depressed sometimes too'; which is like telling someone who is paraplegic, 'my leg falls asleep sometimes too'. 'Why didn't I think of that? I'll just get up out of this wheelchair and walk it off!'

In fact the symptoms of mental health problems sometimes can be just as obvious as broken legs and heart attacks. But because we don't understand the functioning of the brain on a physical level, IMHO people assume that what they don't know doesn't exist; and of course they fear what they don't understand, its implications for them, and don't know how to handle it, so they deny it or minimize it.

I think these questions provide perspective to people: Would you rather be unable to walk the rest of your life, or live feeling true hopelessness the rest of your life? Would you rather be blind, or be unable to form relationships with people and be trapped in isolation? Of course, 'none of the above' is everyone's choice.

Antidepressants are overprescribed (just like how Ritalin was like 15-20 years ago) because they work so well that doctors reach for a pill as their first course of action while ignoring other less life altering options.

Some people also find themselves with side-effects like suicidal thoughts or loss of sexual functions that can be devastating, and in some cases will last beyond the use of the medicine.

They are also prescribed frequently because many people's first line of psychiatric care is their primary care physician, who is rarely trained in diagnosis or treatment of mental health issues, but is prepared to write a script.

Serious psychiatrists combine multiple approaches; for instance, many are trained behaviorists. Additionally, psychiatrists are more careful about the scripts they write: you might find it hard to get much tuning and medication fitting done with your P.C.P., but a psychiatrist might carefully ramp you up and, later, down and off of a specific drug.

Do you have any evidence for the efficacy of antidepressants that others, including their manufacturers, do not? In fact, SSRIs/SNRIs are not particularly effective -- at least no more effective than placebo.

My comment on the effectiveness of antidepressants is in reference to the way many doctors seem to view these drugs, not based on any particular studies or evidence.

>I don't think there would be much interest in an article about some imagined overprescription of chemotherapy

Perhaps that's because it's possible to objectively know if someone has cancer? I'm not sure the same is true of depression. I was on an anti-depressant for about a year in college. It didn't save my life and looking back I didn't even need it.

There are guidelines for determining if someone has depression and/or other mental health diseases, just like any other disease. You can't take an x-ray and see depression like a tumor, but you can talk to the patient and their family to gauge and track symptoms.




>There are guidelines for determining if someone has depression and/or other mental health diseases, just like any other disease.

Psychiatric diagnoses are not "just like any other disease". Medical pathology is objective science, psychiatry is subjective postulation.

>In 2013, Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".


Crohns, ALS, Celiac, and early Parkinsons are also diagnosed based on "fallible subjective judgements", but don't have cheering sections on message boards suggesting that they're not grounded in science.

They're also diagnoses of exclusion with a looooooong list of prior pathologies that are tested with objective measures.

The point being: it's a much higher standard of diagnosis than the catch-all term "depression".

re: celiac

"The Tissue Transglutaminase Antibodies blood test will be positive in about 98% of patients with celiac disease who are on a gluten-containing diet."


>Crohns, ALS, Celiac, and early Parkinsons

There are biological tests/indicators that are conducted for all of these pathologies.

There's an undercurrent here that I find troubling, and I think it's the belief that, because psychiatric diagnoses rely on something other than "objective biological tests", mental illness is somehow less "real" than other illnesses.

That's a conceit that only someone who has neither experienced nor been exposed to severe mental illness can hold. One cannot interact with someone that is floridly psychotic and not come to the conclusion that, while the specific diagnostic criteria may be subjective, there is something objectively wrong with that individual's biological functioning.

>One cannot interact with someone that is floridly psychotic and not come to the conclusion that, while the specific diagnostic criteria may be subjective, there is something objectively wrong with that individual's biological functioning

Without any objective scientific proof, this is at best theoretical, and at worst mythological.

Such an arrogant assumption has led to horrible conclusions:


Pain management, optometry, and many other non-psychiatric disciplines also rely on self-report. There's no bright line between the 'objective' and the 'postulation'.

>Pain management, optometry, and many other non-psychiatric disciplines also rely on self-report.

That's just plain wrong on the optometry part. While there is a lot of self-reporting used in optometry because it's faster and easier, it's entirely possible to remove it, because you can't fake not being able to read stuff when your vision is too blurry. How do you think the DMV tests your vision? It's not self-reporting; they show you something that you don't know beforehand and you have to read it. Optometrists also use vision tests to gauge your vision as they try different lenses. If they really wanted to, they could move from static tests that you can memorize to dynamic ones to prevent "cheating", but why would anyone cheat on an optometry exam (like they really would for the DMV)?

Sure you can. There are only so many eye charts in use. It's possible to memorize them.

Just being left in the exam room for 30 seconds unobserved would be enough.

>Sure you can. There are only so many eye charts in use. It's possible to memorize them.

No, you can't. Sure, you can memorize the optometrists' eye charts now, but that's because they're not expecting anyone to try to cheat, and just use some printed charts. Why would they expect someone with ill intentions? You're paying them to help you see optimally.

However, at the DMV, they absolutely can test you properly, because their machines (at least the last one I used a couple years ago) can change all the letters around however they want, and presumably every test is different (within the maximum number of combinations, which is surely too high to memorize). They're actually expecting people to try to cheat there, so they don't just use a single printed wall chart, they have a special device you stick your head in.

How do you propose fooling a retinoscope?

Self-report for pain management relies on ontological subjectivity, not epistemic subjectivity.

Sure, what I'm saying is that a doctor found that I met those guidelines (apparently) and prescribed me a drug. I don't think I ever needed it, I was just struggling with a transitional period in my life. It didn't really improve my life, in fact between the reduced appetite and hampered sexual performance I'd say it definitely was a negative. After reading some research about the performance of antidepressants vs placebos and the possibility of my sexual side effects becoming permanent I decided I was out. All of which is to say, are anti-depressants over prescribed? I can say yes, if only by my one case.

In fairness, you don't know what your life would have been like without them. I'm not second guessing your personal judgment, which must include a million factors I have no idea about (and it's not my business), but I don't think that kind of comment is conclusive.

> I was just struggling with a transitional period in my life

Why shouldn't that cause serious depression, and why shouldn't someone need antidepressants for it?

I guess... but you can get away with questioning my personal judgment. What if you went around to all the comments here saying "it definitely saved my life" and questioned their judgment? Maybe it's those people who don't realize their ability to beat depression without medication.

To your second point I would say that a struggle shouldn't necessitate a clinical diagnosis. Life is full of struggle, and equating struggle to depression to medication is why we're in the overprescription business in the first place.

Again, I'm not questioning your judgment. Sorry if you feel that way; I'd delete the comment now if I could. I wouldn't question other people either, and especially, for obvious reasons, I wouldn't question the people you mention.

> I would say that a struggle shouldn't necessitate a clinical diagnosis. Life is full of struggle, and equating struggle to depression to medication is why we're in the overprescription business in the first place.

I know critics repeat that narrative often but I haven't seen evidence of it actually happening. That is, I haven't heard anyone say, 'struggle is a sufficient condition for the diagnosis of depression', and I'm almost certain that the standards for diagnosis in psychology/psychiatry are much higher than that.

> overprescription

I'm not sure that's true either. Certainly there are always some false positives, but what is the rate? The evidence does indicate there are very many false negatives, people who need help and are not getting it.

I suspect the narrative of overprescription for psychological conditions is based in part on two things: 1) People with preconceived negative attitudes toward mental health care, and 2) variation from the norm they are accustomed to, which is that few or no people received mental health treatment.

Regarding the latter reason, perhaps there was a problem with the old norm; perhaps many more people need mental health care than we knew. When there is a new treatment for cancer, we don't say 'it's overprescribed; in the old days we toughed it out.' We don't say that about lead in water. If it's helping people, it's a good thing, and I want to society to move forward, for people to be healthier and happier and not be stuck in the conditions of the 1970s (or whatever the baseline is).

> It's looked down on as if "you just can't handle life" so you "just feel sad".

I think that a large part of the problem is just the name, "antidepressant". If they were called Serotonin Stabilizers or something, maybe there wouldn't as much of a stigma.

The same is true, but more so, with "anti-psychotics".

Having a look at your genetics and microbiome might tell you more about why you have these impairments. Methylation issues or entire genea of microbes missing from the microbiome can easily cause neurotransmitter imbalances that the body cannot compensate for on its own.

Anti-depressants literally saved my life. I tried to manage my anxiety / depression for years with diet, exercise, therapy, mindfulness, and meditation without great success. 2 weeks of lexapro was a night and day difference. Don't be afraid of medication if other options fail.

I concur. Don't be afraid of the medication, just make sure to consult a (good) qualified professional that helps you figure out the right prescription for your particular scenario, and don't fall in the overuse/abuse trap.

Same here. Lexapro made most of my depression and anxiety go away. With that initial chemical help, I was able to double down on my exercises and good dieting. Before SSRI's, I did not have enough "drive" to exercise hard or eat well.

> 2 weeks of lexapro was a night and day difference.

My girlfriend thought that lexapro had helped her years before she met me...

She escaped from the psychiatrists who only cared about making her feel worse with their "anti-psychotics", and got her new medical providers to prescribe lexapro instead. After a week she realized that her new rapid heartbeat was certainly caused by the lexapro. She took her last benzo (class of "anxiety" drug that makes anxiety worse over time), and it was all downhill from there...

SSRIs were approved on the basis of fraudulent science. The legal profession was recently able to secure a $3 million verdict against Glaxo Smith Klein - a rather successful lawyer jumped in front of a train after a few days on Paxil. Here's a writeup: https://www.madinamerica.com/2017/05/change-in-chicago-the-d...

So Glaxo Smith Klein misrepresented adverse effects of paroxetine. This doesnt mean at all that the science behind SSRIs is "fraudulent". SSRIs are among the best researched psychopharmaceuticals. And it is true that benzos make anxiety worse, long term, but that doesnt mean that they arent a valuable medication to treat anxiety.

Prozac was always defective too. The German FDA refused to approve it, way back when.


The drug industry has a habit of coming out with a new "class" of drugs as soon as the patents for their old drugs expire. Or they patent a new combination for old over-the-counter chemicals. My father recently got prescribed something with a retail price of >$1000. He said he could buy the two OTC pills for about $15... this was something for his stomach + an nsaid, iirc.

The "German FDA" has certainly approved of fluoxetine (Prozac), which is simply sold under a different name there.

maybe they eventually approved it, but they passed on it in 1984:

  – Three years before Prozac received approval by the US 
  Food and Drug Administration in late 1987, the German BGA, 
  that country’s FDA equivalent, had such serious 
  reservations about Prozac’s safety that it refused to 
  approve the antidepressant based on Lilly’s studies 
  showing that previously nonsuicidal patients who took the 
  drug had a fivefold higher rate of suicides and suicide 
  attempts than those on older antidepressants, and a 
  threefold higher rate than those taking placebos. [1]
[1] http://www.baumhedlundlaw.com/media/boston_globe_prozac_revi...

Two more links from this site ("note-to-self"): https://www.baumhedlundlaw.com/prozac-time-line/ https://www.baumhedlundlaw.com/our-successes/advocacy-campai...

There's no "maybe" about it - Prozac is available in Germany, just under a different name.

>She took her last benzo (class of "anxiety" drug that makes anxiety worse over time)

Can you elaborate here please?

There are questions about long-term benzodiazepine use, and among the more reliable studied results is that their efficacy can decrease over time. Benzos are useful for acute care but depending on circumstances might not be a sound long-term treatment.

basically what tptacek said... Benzos' are sometimes useful for acute anxiety, but this is not how they're commonly used.

Benzos: A Dance With the Devil - https://www.madinamerica.com/2016/07/benzos-a-dance-with-the...

Benzodiazepine category - https://www.madinamerica.com/category/psychiatric-drugs/benz...

Wow, that's scary, the one about a grand mal seizure with Xanax in particular. I used to take that, but only for occasional acute anxiety, never on a regular basis. It seemed to help a lot, and unlike the SSRIs I've used, it didn't have any obvious side-effects at all. I never took it long enough to get any build-up though, just occasionally if I was having a really bad episode.

This is also my story. Tried everything and only the meds helped.

In the presence of the medical industry's status quo of "we have no studies demonstrating any harm from this drug", and the presence of next to no safety studies at all, all you can really say is you lucked out in the genetic lottery.

The fact is, these drugs do harm people. There's a reason homicide and suicide are listed as a side effect in the drug insert of all SSRI's. Your testimony is correlation. But that in and of itself does not establish causation of a positive outcome for everyone.

So? I hear all sorts of bullshit from armchair psychiatrists trying to scare people from using SSRI's. I'm saying, it might work for you, like it did for me. Or it might not. Might as well try if other things don't work.

You zealously omitted the "it might not" part from your comment.

Do you have a way of knowing whether the Lexapro was more effective than a placebo would have been?

There are plenty of anecdotes here, which are fine for those wanting to share their story (I've been on two types of antidepressants myself). However, the point of this article is that there is insufficient long-term data. Anecdotes do not a longitudinal study make. And one of the major problems with depression is that it's subjective. Antidepressants have major onset side-effects, that take around a month to stabilise. So, you're feeling pretty crappy, but take the pills in the belief they'll make you better, and you have some strategies to deal with the nausea and other side-effects. In that onset month, you're probably feeling even crappier than before. But then your body/mind adjusts, the onset side-effects go away, and you feel better. So you report that you feel better after one month. Which skews the data pretty badly, as it's hard to be objective about how good/bad you're feeling at the best of times, let alone when you're in a slump and/or feeling nauseous from the drugs.

For all of those people who say that antidepressants saved or improved their lives (or the life of a loved one), spare a thought for those where antidepressants led a decrease in quality of life, or worse.

This hits home as my wife was admitted to a psychiatric ward today, again, for major depression. I am lost, with a business to run, a full time job in addition, two daughters, and struggles with minor depression and anxiety myself.

She is on two antidepressants, Vyvanse (amphetamines), Provigil, and then takes trazadone to sleep. Her Dr will first increase one, then after that fails will add another or switch her. She's treated like a human Guinea pig. No one has thought to question whether the medications contribute. No one has looked at the problem holistically. Her diet is absolute shit, she doesn't exercise, she really doesn't take care of herself at all. And the medical professionals all tell her it's not her. She has a disease, she has a chemical imbalance, it is completely out of her control.

Long story short, I see both sides. There most certainly IS personal responsibility. Even more damaging though is the state of psychiatric and mental health. It's learned, and reinforced, helplessness.

Man, that sounds rough. Puts some other problems into perspective. I feel for you and hope you guys pull through. I say this as someone who has been through worse stuff in my life than most people.

I don't have much to add, other than I feel for you. I hope things get better for you, and for your loved ones.

So you don't think your lifestyle as listed above has anything to do with your anxiety and mental health issues?

Take care.

I see a lot in here about the popular "chemical imbalance" theory, which is worth noting is more of a big pharma sales pitch at this point in time than actual objective science.

Antidepressants and the Placebo Effect https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592645/

Antidepressants versus placebo in major depression: an overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

You picked two articles that fit your worldview, and ignored all the critique around them. That's not objective science.

Also, even the first one of the articles you quoted clearly says in the conclusion that there is an effect to antidepressants.

Here is one of the articles the critique of the critique you mentioned: http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepre...

>fit your worldview, and ignored all the critique around them. That's not objective science.

^This is an accurate description of western psychiatry in general, ironically, because 1) psychiatry is not objective science 2) psychiatry assumes individual deviation from society's norms is the root of disorder, rather than seriously considering the disorder of society's norms at large.

>In 2013, Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests


>In 2013, Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests

Well, in many areas the biological tests are simply not there yet, and subjective judgements are the best we have.

In many fields, subjectivity is the best we have. In business management, venture capital, and even certain branches of software development, the best decisions are still being made based on fallible subjective judgements.

I may be wrong though - perhaps you can show me a biological test that will differentiate between attention deficit caused by biology, versus one caused by bad habits?

>In many fields, subjectivity is the best we have. In business management, venture capital

Indeed, and I see nothing wrong with that.

The issue I'm critizing is when a group of people fraudulently present themselves as doctors and scientists (implying physical objectivity), especially in regards to metaphysical matters such as the mind.

The catholic church did this during the days of the inquisition, and psychiatrists have been doing the same since the field was invented ~200 years ago.

>perhaps you can show me a biological test that will differentiate between attention deficit caused by biology, versus one caused by bad habits?

There are no biological tests for ADHD.

>1) psychiatry is not objective science 2) psychiatry assumes individual deviation from society's norms is the root of disorder, rather than seriously considering the disorder of society's norms at large.

I believe this is an accurate statement, and the reason for these two points being so extant is that Psychiatry is, these days, more like a state-supported official religion.

Its definitely not science. If you don't think the way society wants you to think (i.e. religion), you are cast out from it: this is Psychiatrys' job.

>2) psychiatry assumes individual deviation from society's norms is the root of disorder, rather than seriously considering the disorder of society's norms at large.

Without making a comment which either agrees or disagrees with the above, I would like to add that I believe those who downvoted comments such as this--controversial and/or original ideas--might consider to instead offer a reason why the comment is likely to be of low value.

For example, I can readily find evidence in support & in opposition to the above comment, i.e. WebMD states a primary symptom of Paranoid Schizophrenia to be a belief that the government is spying on you[1]. Another example: gay rights activists of yesterday would be able to tell you of a time when their sexual preference was considered a disorder.

So while the idea might be controversial, I don't believe it is inherently of low value to add to the conversation.

>1) psychiatry is not objective science

There is a reasonable argument to be made that there is merit in being critical of what we do, and don't call, science. Richard Feynman talked about this fundamental, simple nature of the scientific method and the critical component being that it provides a testable hypothesis that can be observed and repeated, which shows us nature agrees with our theory[2]. As we all know, this is very hard to produce in psychology, despite their best efforts to use maths and stats to create studies which find strong correlations.

1-http://www.webmd.com/schizophrenia/guide/schizophrenia-paran... 2-https://www.youtube.com/watch?v=0KmimDq4cSU

Indeed. It seems there is much to learn about how this pseudo-religion is used by the powers that be in order to maintain control:


>more like a state-supported official religion

You might find The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement by Dr. Thomas Szasz interesting[1].

In this book Dr. Szasz historically shows the startling revelation of how modern psychiatry evolved out of and is the modern day equivalent of the Inquisition. As the church lost its control over the state during the Enlightenment, witches were relabeled as crazies and the supralegal role of social control was taken over by the psychiatric state.


This is a terrible article.

It leads with a random three paragraph anecdote about coming off an SSRI. This is a pretty well-known and well-documented phenomenon, and contributes nothing to a discussion of their safety.

And then:

    > But many experts believe these drugs
    > do more good than harm
Followed by a quote of someone saying the opposite, and nothing more to back that statement up at all.

    > Many SSRI users report blunted emotions
That's kind of the point

    > “They should be called anti-sex drugs
    > rather than antidepressant drugs,” says
    > Jon Jureidini, a *child* psychiatrist
Seriously? They're quoting a paediatric psychiatrist on the effects on libido of anti-depressants. Just a thought: if you're a child psychiatrist and your patients are having lots of sex, there may be other issues affecting their mental health.

The article gets no less sloppy. Clickbait is clickbait even when wrapped up to look vaguely scientific.

They don't talk about SNRIs like venlafaxine in the article, but I can say from first had experience that the withdrawal symptoms from those are pretty extreme. This is a difficult decision, but I've decided to not take SNRIs or SSRIs to manage bipolar depression, although they are commonly prescribed because I found the side effects to out weigh the benefits

I've been on venlafaxine 75mg (prescribed 150mg, but didn't like the increased side effects) for about a year now, I felt elevated mood a bit, but it did little to address bipolar cycling in my case. Recently I was prescribed Lamictal (lamotrigine) off label by my psychitrist as a mood stabilizer. I have just this week come up to therapeutic doses. It has been a huge change. I don't feel like I have experienced any additional side effects, and my mood is much more even. If you've never tried it, you may want to do some research online. Many bipolar patients have reported similar results.

Lamictal carries the potential for severe side effects, much more so than SSRIs/SNRIs. Lamotrigine prescribing information has a black box warning about life-threatening skin reactions, including Stevens–Johnson syndrome, DRESS syndrome and toxic epidermal necrolysis.

I currently take 5mg of Abilify

I wonder why people care whether or not somebody else really needs them.

For arguments sake, let's say they don't. Suppose they can just man up and learn to deal with their first world problems. What do you lose by them taking something to make that easier?

Do you normally fix all of your other problems in the most difficult way?

We all seek ways to get an edge, if not against others, then at least to reclaim some of our own time and well-being.

From their perspective, there are 3 kinds of people. There's the positive, motivated guy who can't wait to get out of bed and go make his mark on the world. Then, there is the similar character who has to take SSRIs or whatever to keep that going. Then there is the lethargic person who has to fight every day to pretend to give a shit, can't keep relationships together, doesn't get promotions, and doesn't feel motivated to learn new skills or hobbies.

The last person doesn't really have the option of being person #1, but they may have a choice between being #2 or #3. Since all three of them end up in the ground after a few more decades anyway, why does it matter to others how they get there? Maybe the last 10 years or so of their life will cause them complications due to longterm use. It's hard to view that as a bad trade for folks who were miserable and/or suicidal for the first 50.

>What do you lose by them taking something to make that easier?

Going with your argument, one stands to lose on at least two fronts:

1. severe side-effects

2. potential long-term harm stemming from chronic use (as per the present article)

>Do you normally fix all of your other problems in the most difficult way?

This is disingenuous. The argument is that fixing depression sans medication is a better (= safer, more effective) way.

Granted, this argument is far from being obviously correct. Things also get murkier when we admit that there are various forms of depression, but that's not the point. The point is rather that you're arguing against a straw-man.

Neither 1 nor 2 answer the question. Why do you care if they do it? You suffer no side effects or long term harm.

They certainly do answer some of the questions you explicitly spelled out. As for the rest:

1. I generally care if people are being pushed towards (under|in)-effective treatments. I want people to be guided towards the safest and most effective treatments for ethical reasons.

2. I worry that there are misaligned incentives between the drug consumers and the drug suppliers.

Maybe out of genuine concern for their fellow man, their suffering, and the possibility that parts of the medical establishment have perverse incentives. If you're arguing just to argue, you're an asshole. If you really feel that way then I feel sorry for you.

The medical model of mental and behavioral problems is a lot better than the moralistic model.

But physical health is also a poor metaphor for mental health, and this article reveals some of the reasons why. Like the doctor comparing the antidepressant use to insulin, even if the doctor was just trying to de-stigmatize the anti-depressants.

But human minds and personalities grow and change in response to the environment they're in and as part of normal aging and development.

I wish the biopsychosocial model would catch on. Maybe it needs a catchier name.

I'm building a browser game that educates people in this. There is nothing I can publish yet, but shoot me an e-mail (kolinko@gmail.com), and I'd love to discuss it in more detail.

(I hope I don't break any HN rules with this comment - there is no landing page, and I don't have a public pitch I could share here yet).

Whether you view the drugs, and their long-term use, as a benefit, or not, here's how I see it. The pharmaceutical companies have these drugs approved. And they are being prescribed and used, long-term.

So, what's the benefit for them in doing longitudinal studies? What's the upside, versus the potential downside of discovering negative effects?

If you want longitudinal studies, you're going to have to look outside the industry.

An essential reason we need to keep government research around and well-funded.

First, everyone's depression is specifically their own. While there are groups of people who react similar to each other, that doesn't at all negate the experience of other different groups and their reactions.

I take an SSRI. It's worked well for me. If the cause of my depression is a defect in the serotonin path, then I see no reason why I, with that particular problem, should wean myself off my SSRI; I don't think SSRIs repair the serotonin path, they just mitigate the defect (production or transmission).

If I had a defective leg, with no hope of repair or regeneration, I wouldn't try to wean myself off my brace.

Same with ADHD and dopamine release. It is why amphetamines are so effective at treating legitimate ADHD. Mundane chores everyone has to do go from unimaginably difficult to start to moderately rewarding with the magic of a brain releasing its pent up dopamine. It isn't even a dopamine production problem for many with ADHD, the brain just won't release it like it does for most people. You can train it to some extent, but the defect will always exist in the ADHD brain.

I was on various medications off and on over 6 years. I needed them before that but they helped immensely once I had them.

However, I've found that they're unnecessary and even detrimental long term, if you can tackle the underlying reason behind the depression (the side effects can be huge). For me, it was a lifestyle change that involved better diet and exercise (like everyone recommends), as well as associating myself with people that I enjoyed being around and who encouraged me to be better and disassociating myself from people who brought me down.

The most important piece, however, was that I was able to fundamentally change my thoughts and perspective on life. Instead of telling myself "I'm a failure" I tell myself "I found one way that doesn't work." Instead of "I hate myself" it's "how can I make myself better?" Instead of "they don't actually like me" it's "I don't care, because I don't need everyone's acceptance to be content." I was able to do this mainly through reading various mindfulness books but most importantly Stoic philosophy. "A Guide to the Good Life" was fundamental. The rest came through general maturity through life experience, accepting the world the way it is and coming to terms with it, as well as using that knowledge to get what I want from it.

A combination of these things, plus finally becoming financially independent and moving to a place that suits me better, has led me to believe that for me antidepressants are a temporary tool to help you learn to manage depression. There may be a chance that I need them again in the future but I feel very secure where I am now, and more confident and happy than I have ever been in my life previously.

What has led me to believe that the same also holds true for most people is that I've known many other depressed and medicated people before in my life. What I find in almost all of them (who remain depressed and medicated) is that they view the medication AS the fix, instead of the tool that helps you find it. They accept that the medication will bring them enough contentment to live out the rest of their life. Because of this, they never try to change it. They're living the same life they were, except now they aren't as miserable.

Maybe it was a good thing that the side effects were too much for me but I wasn't able to live that way, they forced me to find a way to improve my situation. I believe that many people just haven't been able to find the right ways to change their life to live without medication. Of course, this doesn't apply to the ones that can't fix their situation for whatever reason, but the reality is that a lot of people are being medicated, and most of them do have the power to change their lives to render medication unnecessary.

> they view the medication AS the fix, instead of the tool that helps you find it

This. Professionals should explain that these medications are a tool to help you manage rather than a "fix" you should be taking your whole life. It is possible to figure this out on your own, like the OP did, but not everyone can.

I wonder how much of Sarah's issues were a "nocebo" response, thinking that withdrawal would be bad. If so it might help if doctors and pharmacies provided a "guided reduction" (e.g. you get 19mg one week, 18mg the next etc). People might feel better just thinking that an "expert" has designed this program.

I don't know about Seroxat, but I've experienced undeniable symptoms withdrawing from antidepressants: "brain zaps" that I had no idea about until I started experiencing them, then found other people who had written of experiencing them as well.

Additionally to those, I had a weird whooshing sound that I would hear whenever I moved my eyes to the top left. Took me a while to figure out the pattern/trigger (seemed random at first, and I thought I had something stuck in my ear). Actually kind of fascinating, if scary.

That was on top of the nausea etc. And this was a 'guided' withdrawl (under medical direction).

I don't discount that there might be a placebo/nocebo response in the side-effects (both onset and withdrawl) as well (as with any medication)

I've been on different forms of ssri, snris since the age of seven. I'm 32 now. It's debatable my parents used medication as a way of silencing me, as I was lashing out and making suicide attempts and violent threats as a response to my father's physical and sexual abuse.

Regardless, I've been on so long I don't believe I could function without them. Every time I've gone off, whether cold turkey or under a psychiatrist's supervision, I've fell into the deepest, even catatonic, depressions of my life. Even had a psychotic break which required shock treatment.

I've been in therapy, ptsd groups, religiously exercised, meditation, journaling, and a whole lot more, but the medication has always been there. Both sides of my family have a history of suicide, alcoholism, depression, and other mental illnesses.

I feel like an addict but also justify it, in that you wouldn't shame a diabetic for taking insulin.

Ok, I can't resist this.

First, chunk of the reason why SSRIs and to a lesser extent benzodiazepines are (perhaps) overprescribed is that they are safe, at least in the short term. In the bad old times antidepressants were dangerous, let alone antipsychotics and such.

There's some interesting literature pointing to lithium as the Stephen-Curry-mit-Keith-Jarrett standard for long-term management of treatment-resistent depression, but man, taking lithium sucks. If all I had was the garden variety blues I would sure opt for the Zitalocipraoamezaxx they advertise on TV.

Second, I think people are over-eager to blame pharma and not the doctors. These are tools, people, and power tools at that. Yes, some research released by pharma is biased in that they do not release the unfavorable studies, but there are plenty of blogs out there poring over the technicalia, as well as sharing experiences in real patient care.

Maybe some of these things are overprescribed to the gen pop but they're still useful to us.

Third, isn't funny that we're expected to be open-minded about recreational drugs and puritannical about pharmaceuticals? Effectively in many parts of the world now you can legally buy weed but cannot get Klonopin when needed unless you work through the system somehow.

This should go without saying, but fourth: the goal of psychiatric treatment is never to make you happy or realignm your chakras. A pdoc doesn't ask "are you happy, are you sad", he asks "are you functional?" Meaning first: am I able to work? (This is the first thing -- it's not good for someone mentally ill to be homeless). Next: am I able to maintain and grow my personal relationships? Is my sex life ok? Am I overall satisfied with my quality of life and my ability to take and handle new challenges? If I can't get an erection (meds sometimes impact that), that's something he can try and help. If I'm questioning the usefulness of being a knowledge worker in a society pumped by a bubble of BS? That's on me.

Your goals as a human being are still up to you.

First try legitimate physical exercise, lifestyle changes, counseling.

Not trying to give you a hard time, this is of course good advice, but please never tell that to anyone you care about in a depressive episode. Time and place. Virtually every person with depression has been given this advice a million times. If it were just that, they would have done it. It took me a long time to accept that it just isn't that simple for people with long term depression. That is a huge part of fighting it long term, but those habits are hard to gain and easy to lose, putting someone back in the hole. People with depression also just need people. Support, acknowledgement of their struggle, listening, acceptance. I have a strong inclination to help people fix things. My younger self had a hard time accepting there were things I could not fix or figure out.

It's also dangerous advice. Seek professional attention first.

You're definitely not wrong, but the issue is that these are very difficult things to do in the midst of a depressive episode.

And of course the first ad in the article is for an antidepressant.

Drop the ad script in and forget it they said... Targeted ads they said...

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