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Experimental depression treatment is nearly 80% effective in controlled study (stanford.edu)
611 points by carabiner 4 months ago | hide | past | favorite | 321 comments

While depression can certainly be caused by chemical imbalance and not because of how your unconscious mind impacts/limits your experience of life, I took the approach that exploring my subconscious through therapy was the way to get out.

For me it worked very well and I think the journey is an amazing one to go on. Building from the ground up and understanding all the foundations within. I always wonder about treatments which don't have this benefit, although the results in terms of lifestyle change sound extremely positive.

One of the hardest parts of therapy is diagnosis of what to work on. Even though an issue will be "presenting" itself clearly, it can often be a bit of a decoy. For example, a lack of self-esteem is often a useful derivative of an unconscious fear of upsetting others. Low self-esteem => avoid situations/behaviours that upset others.

During therapy I found dreams, when analysed outside of the "conventional" Freudian/Jungian frameworks provided a simple and accurate method of reaching the root diagnosis (the fear of upsetting others vs. the decoy issue of low self-esteem).

I got a bit obsessed by the topic and wrote a paper on it which can be downloaded here: https://psyarxiv.com/k6trz

And was discussed on HN here: https://news.ycombinator.com/item?id=19143590

Great Post, thank you for sharing.

I do take issue with the commonly parroted claim that depression can be a chemical imbalance. It's a notion arising from pharma marketing psyops, and is largely without utility. It even risks being an antipattern. The few pros include separating responsibility and thus alleviating some guilt, which often coexists with depression, and annoying spiritualists. Tell me if I missed any.

Analogy: if I told you an athlete is different to a couch potato because of chemical imbalance, you'd think I was obtuse. While technically correct on some level that explanation obfuscates useful relational information about training, motivation, routine, mindset, culture, and circumstance. Similarly if I told you to become an athlete by only taking supplements that augment the phospho creatinine ATP pathway, you'd think me a crook.

Oversimplifications sell pills and make for memorable catch phrases, but fall short of empowering us to become happy and well.

Let's try and move our collective understanding beyond chemical imbalance; it's a tired mantra with scant utility.

Disclosure: neuro psych doctor

I'm not sure I understand what you are saying. Just that we shouldn't recognize that depression can be a chemical issue because that doesn't help us fix the problem? Are you saying that anti-depressants don't work?

So if depression is more about mental models, life choices, and drive and whatever, why do so many people suffer from depression in cycles? There is little change from one day to the next, and yet, many people with depression can feel great one day and terrible the next. Or pregnant women can feel great before giving birth and then give birth to a perfect baby and suddenly start feeling depressed soon after.

How do you use therapy to cure depression if the depressed person has no reason to feel depressed?

Okay how about a new analogy:

Your web app malfunctions, and a diagnostic sweep suggests the code is compromised. It's cloud hosted and open source. You're part of a team and see various recent revisions that could have exposed the app to malicious use. Furthermore your cloud provider is upgrading their hardware. Your app has to come offline whilst it's patched. Its a critical service for some clients who are hounding you.

You ask for help from a professional to get things back and working.

They say, "It is due to an electrical imbalance in the computers."

In psychiatry people are analogously doing just that.

We know sure that neurotransmitters have a role in mental health, in the same way as engine oil has a role in a car. Right amount in right place is necessary, but not sufficient, for good operating. If I brough you my faulty car and you jept harking on about engine oil, I'd be miffed.

Incidentally I'm a staunch monoist materialist and believe brain states and mind are facets of the same phenomena. My gripe is with pharma marketing penetrating our collective psychology. Equating depression to monoamine derangement was a very attractive notion for all but in 30 years remains unproven, and not very helpful in guiding treatment.

I think I might have a slightly more apt analogy, though I do understand yours and pretty much agree.

To immediately jump to the "chemical imbalance" problem/solution is like if you have a web app that's performing really slow, so you hire a consultant to take a look.

They tell you that you need to horizontally scale your app in order for it to perform better. In many cases, this would actually work (for a while anyway), but it probably doesn't explain the real issue.

In reality, the problem could be that you wrote your app to do way too many things per request rather than picking and choosing which things are going to be treated as first-class. Perhaps there's even one little thing that's O(n^2) and it simply is going to take a lot of time to work out.

> We know sure that neurotransmitters have a role in mental health

While they have a "role", differences in neurotransmitter levels do not predict mental health state.

My understanding is that "chemical imbalance" theory was a popular misunderstanding of a more limited and specific theory called the ”catecholamine hypothesis" which has itself been pretty much debunked.

For decades the explanatory psychiatric theory behind depression has been the the "bio-psycho-social" model. While we know that biology is an import part of the picture, that part can include a bunch of different factors besides neurochemi cals, such as possibly inflammation, neuron growth factors and more.

[0] https://www.psychiatrictimes.com/view/debunking-two-chemical...

> Equating depression to monoamine derangement was a very attractive notion for all but in 30 years remains unproven, and not very helpful in guiding treatment.

I believe that theory has been mostly disproven, but that doesn't change solid evidence behind the efficacy antidepressants that were developed using that theory.

If someone tells me there is an electrical imbalance with the computer, then I will know we need to fix the computer, rather than the software that runs on it.

with your engine oil analogy, it seems like you are agreeing that brain chemistry is an important part of good mental health, just not the only one.

So if all the other parts of good mental health are in order, that leaves brain chemistry, hormones, etc. As the problem.

Not GP and not even sure I agree with them.

However I think there's some semantic issues with "chemical imbalance" that are worthy of examination. Depending on your basic philosophical views regarding materialism and the origin of consciousness, you might be of the view that all mental states are the result of brain states. This is a reasonable view. Considering what we know about brain function and the rather broad meaning of the words "chemical" and "imbalance" arguably all brain states are the result of "chemical imbalance" of some kind.

(I know the brain is also an electrical system but the electrical pathways are deeply entwined with the chemical ones)

Anti-depressants do not cure depression, they only temporarily relieve it. And they eventually stop working as one inevitably gets desensitized to them.

Sure, but that just further affirms my point that some types of depression are simply chemical.

There can be many reasons for that and most have nothing to do with life choices or "mental models" whatever that means.

* Trauma triggers and unprocessed/unconscious trauma. You'd be surprised how common this is. People who grew up in neglectful or abusive homes tend to believe there's something wrong with them and that their childhood was fine. So when life feels like shit, like there's no point, and it's only suffering every day, that somehow other people manage and they don't, they see no light at the end of the tunnel. It must be their fault, and for some reason they can't "get over it" or "Let it go".

* A person repressing stuff, which at some point reaches breaking point or saturation.

* Combination of (unlucky) factors - e.g. winter/less sun, less people around for some reason, had to sacrifice exercise for extra work, (...).

* Chemicals in the brain indeed, change from one day to another. And maybe the day they feel depressed is when they are seeing things more realistically and crash with that realization.

I don't buy this idea that it's part of the human condition that we're bound to have depression sometimes and that it's chemical imbalance. If we look at human history of psychiatry you'll see how coldly we've been treating patients. You'd be horrified at how we treated mentally ill people in the past. Why would you think we're doing any different now, just in a more mODeRn way - "They're sad because their brain is wrong. Give them a pill."

>Chemicals in the brain indeed, change from one day to another. And maybe the day they feel depressed is when they are seeing things more realistically and crash with that realization.

So, you think that chemical changes in the brain can affect how realistically one perceives their situation, but a chemical change that causes one to feel depressed is not something that happens? That doesn't seem like a logical conclusion.

What they are trying to say is that depression pills are as helpful as vitamin supplements are for sports.

If you happen to be a top athlete that’s just not getting enough vitamins, the supplements might help a bit (not as much as correcting the diet though). If you are a couch potato, you might have a Vitamine imbalance, and the supplements might correct it, but the supplements won’t turn the couch potato into a top athlete.

That would require a complete lifestyle change. From maybe new sport affine friends, to better diet, motivation, schedule, training routines, and a big time investment.

The analogy of the OP is that curing depression with pills “is like” trying to turn a couch potato into a top athlete using pills. The fact that the pills do something doesn’t mean that they achieve the goal.

I think we have a lot of double blind clinical trials that show that anti-depressants do work. Not with super high success rates, but higher than vitamin supplementation.

The discussion is often over-simplified in one direction or another, so thank you for bringing up post-partum depression and depression that can be influenced by hormonal cycles. (And by the way, men can also experience post-partum depression -- men also go through hormonal and life changes when bringing home a baby.)

We're all a product of our thoughts, our environment, and the mediating chemicals in our brains and guts. I'll throw in a different complex connection: the connection between hormones (estrogen and progesterone) and histamine. A woman can have seasonal allergies that wax and wane monthly due to the role estrogen plays in regulating mast cell release of histamine. The environment may stay the same over that month, but the chemical soup changes. This change may also be further mediated by what the person eats, as consuming high-histamine foods on top of that might be enough to really set off a physical reaction. Because we're talking about seasonal allergies here, few people would find this controversial.

So, let's move to the mind and emotions, which are certainly more controversial. All these factors are still there. Yes, CBT can be enormously helpful in getting you out of cognitive traps that decrease the quality of your life experience. At the same time, it can be true that you've been eating a diet that is not good for you and your stomach hurts all of the time not because of anxiety but because of your food. Let's take me for instance: I'm in grad school, I'm not feeling good, having trouble getting out of bed, I'm trying to drag myself through the thesis on caffeine and sugar, I keep beating myself up because I'm not as brilliant as Gauss or Kovalevskaya or even that guy who got that TT job at Virginia Tech and I have writer's block, I see the psych person at the health center 'cause why not. She says I have stress-induced stomach problems. Mindfulness doesn't help. What finally helps? An elimination diet that allows me to discover that one simple trick (eliminating a type of food) makes my stomach not hurt, means I don't wake up tired and hurting in the mornings, etc! Amazing to sleep and then wake up rested! Suddenly I have half the problems I had before and have more energy to deal with them. I'm still not Gauss, and that takes another 10 years of life progress to acknowledge. Whatever.

There are many ways to attack problems. Change the input, change the process, change the environment, decide the desired output isn't actually desired. Childhood experiences, diet and exercise (physical upkeep), the "shit life" phenomenon another poster mentions, hormones and chemical imbalances. Therapy is not the cure to everything. Neither is medication. Neither is diet. Sometimes we actually need reform so that people aren't stalked by medical debt or huge bills for having their kids put into foster care or whatever (lots of literature on the connection between financial instability and depression).

Anti-depressant alter your brain chemicals almost immediately once you start taking them but the anti-depressant effects usually come a couple of months after. Which suggests there might be more to the issue than just a 'chemical imbalance'.

Altered brain chemistry influences the physical prevalence of the receptors that those chemicals act upon. Those adaptations can take some time.

I agree with your claim, but in my experience I encounter people who explain mood disorders as chemical imbalances mostly in a different context. Where I see it most often are good-intentioned people trying to argue against stigma and poor treatment of mental illness. The idea is that there is indeed a physical aspect to it and not just "all in your head", and hence should be treated with the same sympathy toward the patients as physical illnesses, and this is directed toward people holding a certain mindset that stigmatizes mental illness as an argument to not do so. Of course, this is a terribly insufficient characterization of mood disorders. Perhaps this characterization in a game of telephone eventually became misconstrued in the popular consciousness as essential to the disorders.

I agree with you that there is definitely some serious obfuscation around the chemical imbalance aspect of the biological theory approach to mental disorder. If you do any research into the history of anti-depressants it isn't hard to uncover that there has been a lot of questionable science that forms the foundation of the over prescribing of medications for mental disorder that is currently the industry norm.

I spent years suffering with really severe symptoms and I was so desperate for relief I tried all sorts of treatments. The main thing I really learned during that time is that approaching mental health requires a holistic approach, but even armed with that knowledge my life was still seriously impacted by my mental disorder. For me, I had spent years in talk therapy and different behavioral therapies. I had also tried various medications which did not help me and/or had side effects that were unbearable long term. I was on lamictal for a while which seemed to help but I also stopped seeing improvements and eventually that was also not good enough and my function declined. I also tried meditation, spiritualism, self medication, yoga, exercise, different diets, journaling. I took class after class on psychology and I instituted all sorts of different systems to try to fix myself. My therapist told me over and over that I was doing the work but that the improvements we were seeing weren't what she would expect, then I was referred to TMS. Once again, I was desperate and I was willing to do or try pretty much anything because I was a wreck of a person that was spiraling dangerously. So I went, and for the first time about three weeks in... I started to see a small difference. It changed my life, and I'm still so much better. The thing about how well it worked for me though is this: the idea of TMS is that it targets the part of your brain that is damaged by depression. Whatever this means- I've come to imagine it as neurons that have formed hard wired patterns of depression that are nearly impossible to rewire through sheer force of will. So chemical imbalance- probably (even demonstrably)false. Physical patterns in the brain formed while you suffered from depression being very difficult to rewire without outer interference? Is that possible? I'm mostly thinking out loud and I don't really expect someone to just have the answer but I really want to know and it's something I wonder about constantly.

I think the main problem we view depression as a disease when it is a symptom with several possible causes. Most people I know haven't done the deep introspection when life circumstances or past in some cases preverbal traumas exist.

Additionally, we're generally told quite a lot of lies and made to believe fantasies from the earliest ages about - the world, who we are, and our place in the world. I have a theory and it's just a theory when we get misaligned with certain, let's call them, cosmic truths - there's a mind and body reaction, often outside of our conscious ability to recognize the problem.

> I think the main problem we view depression as a disease when it is a symptom with several possible causes.

I agree. The fact that depression and mental illnesses highly correlate with lack of religion and rise of the secular nation is something that should be investigated more.

Do you mind expanding on your theory a bit? I think I agree with you.

There are a few psychological constructs in our head that really tie deep into the mental pain

I forgot who i saw recently that said we have a strong mirroring need in our brain, which means our happiness is extremely relative, if you suffer while people don't .. it hurts more; if people are in the same boat the pain gets softer.

Oh and yeah unconscious fears are often the root of so many mental issues.. abandoning (to) fears is often a massive trick.

I'm not sure what you mean when you say abandon (to) fears. But my experience was that when I could pinpoint the fear, overcoming it by facing it was the way out.

Often as infants we develop legitimate fears in the context of our vulnerable position and extreme dependency on maintaining the parental relationship. These fears made sense then and helped us keep our parents calm, but interrupt our adult lives. These fears are also extremely powerful as our infant brain associates breaking them with a risk of death (typically through abandonment).

However, the brain seems to be remarkably fast at unlearning these fears when it realises they no longer are needed (I will not die/risk death by doing the "forbidden action"). So my experience was that pinpointing the fear, facing it in my life (perhaps initially in the context of the safe relationship with my therapist, and then outside in the "real world"), and watching my anxious reactions which were previously flared up in situations where I was avoiding the forbidden behaviour fade away. It leads to a calmer mind with fewer and fewer situations in daily life which cause anxiety to arise.

Curiosity: what if you've done so and your fears have been reinforced instead?

Background: after a difficult childhood, I did a therapy, discovered self improvement and lived a few years where I faced fears regularly and expanded massively. However, multiple debatable decisions built up to a point where everything broke down. Lost my job, hoped on 3 jobs even worse afterwards, was morally harassed, and the resulting bad mood and general negativity made me lose friends, and be even more vulnerable. Loss of confidence made me sabotage more or less voluntarily other aspects of my health, balance and projects. Therapists, SSRI, etc. no way to get out of it (just lots of money taken away => even more pressure/problems). It felt like death since I had to go through these many years, helpless, hopeless. It was worth than any experience in my childhood, and still traumatizing.

Now, the absence of "death" at an instant t when doing a "dangerous" action doesn't mean that death can't come later as a consequence (ex. tell your opinion at work -> doesn't kill you but if it leads to be fired later and start a cycle like above, it can be dangerous). Therefore there's never validation that my actions don't kill, they're just written on a list, with consequences pending, and the fear of the ultimate judgment is impossible to confront, unless it all happens again and this time I manage it. How would you confront this kind of fears?

Sorry you had to endure this. It's true that adult life is wide and chaotic and you can slowly end up in a black hole situation.

A bed room theory is live small and grow through tiny risks. Small means your life is easier to secure and you can try stuff and fallback as soon as something goes wrong.

It's only a theory, that came up through the realization that a lot of pain comes from bad obligations. Too much mortgage, obligation to stay in a toxic job. Also contexts too large to really know if what you can do or not (such as politics at work).

Thanks, very thoughtful of you.

I was saying almost the same thing as your last line to a colleague, taking many responsibilities in parallel before waiting for full closure, can lead to failing something that you would normally be able to do, just because you were stressed out by the other things you had to do in parallel.

what I found hard is:

- being able to recognize what are too large obligations, with time your nose becomes better at avoiding them quick

- being able to recognize how much I want to bear

- learning to say no thanks

It was a poetic wording that popped into my mind a times. The image of abandoning all defensive reflexes and walking into whatever context you were afraid of and see how it feels.

There's a tendency to avoid seeking reality and stay in fearful predictions based on limited data that we gathered.

All this is probably close (if not same as) CBT. And Yoda :)

That said I often fail to do so. But I used to never try at all.

> There are a few psychological constructs in our head that really tie deep into the mental pain

Indeed, one of those is the 'chemical imbalance' theory of depression, which in itself can lead to a person believing there is no hope because they just are a bag of chemicals.

The way out of this particular conundrum is as the OP stated - therapy which addresses the cause of the imbalance, which has every indication of being an effect of the depression, rather than the direct cause. Change your mind through therapy and non-physical means, then watch the bag of chemicals transform...

So, what type of therapy should one seek out if they get severe depression for a week or so every month, always during their period?

If the "theory" that depression can be caused by chemical or hormonal imbalances is wrong, then what externality is causing such severe depressive swings on such a regular basis, like clockwork?

What "mindset" should a pregnant mother with a history of post partum depression put herself in so that she doesn't feel depressed even after everything goes great and she has a perfect baby and all the support she needs?

> which in itself can lead to a person believing there is no hope because they just are a bag of chemicals.

I'd expect the opposite effect. If we are bags of chemicals, we can change ourselves by altering the composition of chemicals. The hard part is finding the proper balance.

It may not be as simple, i had pills that did influence chemistry (first take was a surprising experience.. feeling your nervous system shift toward mellow was strange). But mental construct of loss were still causing pain as high as before.

> While depression can certainly be caused by chemical imbalance

I'm still not convinced this is true. I think it is just as probable that any apparent "chemical imbalance" is actually a symptom, not the cause, and while treating the symptoms can alleviate some of the suffering it is not a cure.

I want to echo this. I spent many years in therapy getting to the root of my issues stemming from childhood. It was the most fantastic and arduous experience I’ve ever done.

Therapy helps cultivate self awareness which in turn strengthens inner dialog and allows you to reflect on yourself, almost in third person.

It’s a shame our society stigmatizes therapy to such an extent but it really is a miracle cure for many mental health issues if you put the work in.

I agree about dreams, but I don't know that Jung was quite so prescriptive; he tends to eschew frameworks himself. He essentially says about dreams: we don't know why they work, but they do.

From my limited readings I think you are correct, Jung's technique seems very dissimilar to Freud's. AFAIU Jung emphasized that the terminology used unconsciously by the patient in first describing a dream contained most if not all material from which to derive potential theraputic benefit, and that dwelling on some deeper meaning or symbolism was generally a waste of time as then the patient (or therapist!) begins seeing what they want to see.

“I don’t procrastinate anymore,” he added. “I’m sleeping better. I completely quit alcohol. I’m walking my dog and playing the guitar again, for nothing more than the sheer joy of it.” Most importantly, he said, “I’m remaining positive and being respectful of others. These are big changes in my life.”

Serious question: are these typical signs of depression? Now I'm wondering if I have depression.

I've had depression for 20+ years and the best way I would describe it is like this:

Think of that little "kick" you get when you think of something you want to do. Maybe you like eating ice cream, maybe you like playing tennis, whatever it is... that feeling, that subconscious little mental boost that gets you up off your ass, and moving... is completely absent in the depressed mind.

That spark that initiates and sustains action, is simply not there. Tasks, even small ones, are giant and the future is hopeless.

It took me a while to realize that most people don't consider suicide as one of a few strategies to deal with everyday problems. Thought process: I don't want to do my homework. I could (A) get up and do it, or (B) kill myself. Happily, I've learned to dissociate myself from the part of my consciousness that thinks that way.

My thinking is slightly different in this case then yours:

Ending it today will stop having to do x today, tomorrow and rest of my life.

So it's not just the homework of the day.

But due to my thinking I would also not just go without consuming my money and doing only what I want as long as possible as it also freed me from certain social boundaries.

Like suicide is bad, you need to work, lifing as long as possible is good etc.

My thinking was always comparing it to a crappy movie at a middle of nowhere theater. Sure the movie may be bad, but it still beats getting up and leaving.

How many bad movies you gonna watch until standing up and leaving becomes the better choice?

One problem might also be that in my opinion lifing as long as possible is not the right answer. I'm not life positive like independent how shitty your life is as long as you are alive is good.

Now the question arrives what is a good time to leave.having already seen and done more than any other human who lived 50 years ago already puts me ahead on a experience level .

So determine this answer is open for me to decide.

Not having kids and not planning some right now also makes me more 'flexible'

I'm dealing with something like this too. It's come up a lot while watching shows where some protagonist's friend turns psychotic and they suddenly must fight to survive. I keep thinking to myself, "just give up and let them kill you, it will be better that way!" I can't quite pinpoint the theme that seems to permeate all of these and how much of it is my own perspective versus some specific genre. I think of it a lot while watching The Future Diary, and also Higurashi: When They Cry.

Given those two options, I'd end up choosing A. So thinking of B would actually be motivating. It wouldn't feel suicidal to think of both of those options.

The mental illness is when option B in this example seems preferable to small inconveniences and embarrassments, and when one doesn't think of things like, (C) forget about it and go hang out with some friends.

Life is full of small inconveniences and big ones time to time. It's not just one small one. So wanting to stop all that should not be considered illness, but forcing to continue the pain and trauma should be. Life is ultimately a meaningless thing, and most people suffer for it. Some people are privileged and they decide what is illness and what is not based on their own life.

One has to work 9-5 whole life that slowly kills their health and die horribly. That's normal, but if one does not want to continue that, it's illness. One must suffer. There is no other way whatever people here says, the real world does not work in any other way.

You're just arguing the semantics of "illness". Call it atypical thought if you prefer.

Semantics changes everything here and that's how everyone perceives things.

> suicide as one of a few strategies to deal with everyday problems.

That’s as much a solution to everyday problems as nuking the entire planet and the human race out of a existence is a solution to, say, Covid or hunger.

Indeed. Thus we describe that experience as mental illness.

Why is wanting to stop pain and trauma is illness and wanting to continue in more of that useless suffering is normal? I am not talking about privileged here but most people who struggle whole life in world.

Because if suicide were typical, humanity wouldn't exist. Mental illness is merely abnormality, not necessarily something ethically wrong or illogical given one's a priori beliefs.

> Mental illness is merely abnormality, not necessarily something ethically wrong or illogical given one's a priori beliefs.

I agree, but what you're saying is not how the world see it. Many things that make humans exists are not necessary or makes life difficult now anyway. Like phobias, vomiting while travelling by car, allergies etc.

The thing about everyday problems is that they are every day. It isn't just looking at having to do your homework today, it's having to do your homework tomorrow, the day after that, and the day after that, out into what may as well be infinity.

Homework isn't a great example, but you can substitute anything that causes you suffering. For me, a lot of it is about my weight. I went through more suffering than most people can imagine to lose more than half of my bodyweight, and I was pretty happy with the result... until I started letting myself do the things I'd had to give up to get there: eating out with friends (or even attending any event with food), not doing intense workouts more than 3 days a week, having the occasional snack, eating something other than protein bars every meal, etc. My weight started increasing, naturally, and I realized: I never get to stop going through all that suffering if I want to maintain my weight. Ever. Ever. And without being able to maintain that weight I instead get to feel like a fat piece of shit for the rest of my life instead. Given those two options, the idea of just ending my life here and now doesn't seem so bad.

Nuking planet is different as it will nuke all other species. Removing only humans is a solution that actually works for better of everything else things.

Life is constant struggle for most humans (not talking about privileged here). In the end we all die horribly going through all that trauma, so peaceful suicide like hypoxia may be a solution to stop the suffering.

"You asked me how depression felt, and this is all I could come up with. It feels like I’m walking upstream through a current strong enough to pull me under four times over.

There are others with me but they are walking along the banks telling me to “just get out of the water.”

But instead of extending a hand in help, they just move on and leave me behind.

Every once in a while I find a rock that is strong enough for me to lean on, And I can rest for a bit.

But the rocks always get tired of holding me up, and when they let go, I’m left drowning, thrown 50 feet back again.

And nothing is harder than standing up in that current when everything in you is telling you how much easier things would be if you just let yourself get dragged under."


Does that apply to things you 'have' to do as well?

I don't really like shopping for groceries, but I'd rather do that, than order take out that's expensive and probably not very healthy.

If I'm going to cook something, I'd rather cook something with a different taste than eat pasta again.

I don't really want to do laundry, but I do want to have clean clothes that don't smell.

If I could afford to do so I wouldn't work, but until I retire that's not possible, so I might as well make the most of it and increase my earnings/time ratio.

I don't really want to go see my family, but I feel I have a duty to do so.

Does that apply to things you 'have' to do as well?

For some folks: This is the reason for a shower becoming a monumental victory in one's day: Sometimes just getting out of bed is a struggle for folks. I'm in a few cooking subreddits, and often get folks looking for "depression food": Food that takes no effort (cooking at all can be too much effort) yet is still a bit healthy. At this point, you probably aren't enjoying food anyway. I've known someone that literally bought new underwear because laundry was the more difficult option.

Not everyone has all of this, and folks are pretty good at hiding it from others and putting on a happy face.

I have seen a person so depressed they didn't even care to get out of bed to have a bowel movement. They just stayed there in it until someone else came to clean it all up.

Yes. Depending on the severity of the depression, a depressed person might have problems with even basic things as brushing teeth and showering regularly and being able to do household chores.

There are non-depressed people who also struggle with this, I think.

Things like ADHD can make it a real struggle, although depression is a frequent comorbidity.

Yes, that's how symptoms generally work. Symptoms are signs that may or may not point toward a diagnosis. A diagnosis such as depression is something separate that is determined from the collection of symptoms on an individual by a doctor.

maybe they are depressed and just don't know it.

I'm not a doctor, but from what I've heard and seen: many depressed people manage to put up a good facade.

(Of course, that doesn't mean that putting up a facade means that you are depressed.

Also going out and doing stuff is probably better for you than sitting at home, no matter if you are depressed or not. And if that drive to make you go grocery shopping or meet people is less than healthy, that's still better than losing all motivation for everything, I guess?)

I just wanted to follow up on this as well. I also have my groceries delivered because grocery shopping is incredibly overwhelming for me and I suffer from several mental disorders. Something that I have learned is part of learning to live with mental disorder is giving yourself the grace that even if you can force yourself to do something that is very hard on you it is totally valid to find a hack to help you out(like getting your groceries delivered). This might sound like a no brainer for a neurotypical person but allowing myself access to tools to alleviate stress was seriously difficult for a long time because I felt like to be a "healthy" person I had to force myself to do things for myself that I thought "normal" people did. I forced myself to do things that were actively destructive to my mental wellness in part as punishment to myself for not being neurotypical.

> I don't really like shopping for groceries

Have you tried a delivery service? Walmart as an example charges $100 or so a year. And then you pay a tip to the delivery person. I think it's worth it to avoid shopping in person, and cheaper than ordering delivery from restaurants.

My wife suffers from agoraphobia and is autistic. We (honestly: she, as she arranges it) do something similar, but we don't live in a country with tipping culture, so its a flat 100 EUR or so (you can also pay per delivery then the price fluctuates, a decent way to evaluate). Sure, it has cons. Sometimes stuff isn't fresh (report, and get your money back), or the expiration date doesn't suit our planning. Sometimes stuff isn't available or its not included. But it really does help, especially if you have difficulty leaving the house for any reason (we got little kids as well). I also find covid-19 a good reason to not go to the grocery store. However, you miss out on the fresh air and increase lack of movement. Get your little children out, for example to the local playground. A dog can help with that, too. And finally, have a buffer storage esp. with regards to non-perishables, just ensure your house or apartment can deal with the extra storage (e.g. we got an American fridge/freezer).

I used to feel the same. What I found was that thinking of chores as a "duty" made it into a something I wanted to avoid. Instead, making these into a fun "mission" turned it into a positive thing I look forward to. Something about adding a good sound track, makes all the difference.

Some examples - Going groceries. Used to hate it. Stressful. Too many people, I'd get social anxiety. Now, I smoke some weed, put on Michael Jackson on my headphones, cruise through the store with a smile on my face and a dance in my step. They say Mediterranean cuisine is one of the healthiest diets. OK. So I bought the best Turkish cookbook (https://www.amazon.com/gp/product/0714878154/ref=ppx_yo_dt_b...), and decided this is my new food bible. "Good luck, me! You're gonna need to figure out Eggplant." I've been eating grape-leaf wrapped rice, humus, pita bread, and that kind of thing all week - have never felt healthier. The recipes are easier than you think, and are good for leftovers, meaning you can food-prep and still eat healthily.

Laundry - You might laugh, but I find that on the days where I imagine I'm going to go on a hot date (LOL one day), or meet an important client, or honestly - when I feel most badass (and comfortable!), those days - cool stuff happens. I make a cool connection, have a good conversation, experience something different... So, doing laundry has been a positive way to ensure that my favorite shirts/outfits remain ready for duty, instead of uselessly in a basket.

Work - I was in a bad work situation a couple years back. Failing in-place, in slow motion. I tried to be honest during a review with ny boss, and listed all the things I felt I needed to work on (honestly, coming clean on what I was failing at). My boss took me aside and told me, "Why not get better at what you're already good at, rather than improving on what you're not". It kinda blew my mind... I honestly took a look at one of those "find your dream career" Ven diagrams. What is the intersection of your Passion, What You're Good at, What People Pay for (https://www.authentic.com.au/wp-content/uploads/2015/08/pros...). I broke the seal, asked my friends, "Hey. I'm looking to make some career changes, and could use the perspective. You know me. What do you come to me for?" I was surprised what kind of great answers I got. I'm quite self critical, so hearing this type of feedback was very encouraging.

I find t fulfilling to identify the people in my life whom I truly admire, learn about their life goals, and help them achieve them. It's a really great feeling, and leads to getting to know your friends at such a different level.

Family - Lately, I have been calling my grandmother on the phone. She's 95. I asked her, what gets you up in the morning? Without missing a beat, she told me: "Music." She loves Singing, playing piano, dancing. I decided to learn to make music. I'm not going crazy with it, but I bought a MIDI keyboard, plugged it into Garageband, and have been learning chords to songs I like, taking lessons. I'm telling you - it's such a wonderful soul feeling. I've since found out that many of my family members - some I had "written off" - are into so music. We've truly been able to connect in ways that excite us both. One of my cousins, we've gone from a "I see you once a decade" to the the true feeling of "family"- sharing each other's cool songs we've discovered, favorite bands & albums, to even video clips of our playing music attempts, telling stories, etc. If you haven't given it a try before, piano is pretty fun & easy to pick up (Trust me, I never in a million years believed I could play any instrument). Now I can sit down at a piano and kinda play something that at least makes MY ears smile :) Check it out if you haven't. Thanks for listening to my Ted talk...


I am the same way. My depression isn’t severe enough that I CANT do the things that need to be done, but rather, they take immense effort and personal discipline.

Of course everyone (even non depressed people) sometimes struggle to do things they have to do, but don’t want to do. It’s all about how severe that struggle is, not whether or not that struggle exists at all.

This. And also a gazillion other things.

Years ago I was recommended a book written by a Dutch psychiatrist who had developed depression himself. The tagline was sort of "here's a professional who suffers from it, this will be insightful."

I couldn't relate to his condition for one iota (let alone finish the book); as he had mostly feelings of guilt and shame, and dark, weird mental images.

I guess depression is a sort of blanket term by now for many things, which probably complicates diagnosis and most of all, treatment.

Plus, I recently discovered the term "sh*t life syndrome", which is apparently getting to be known as a well-known term in the US/UK psychiatrics system (at least it has a Wikipedia page claiming that). It describes people who are poor or lonely because of the system surrounding them (prime example: they live in an area with raging unemployment). In that case, it's argued, symptoms of depression might actually be the logical response to an outside stimulus (or lack thereof). Yet, it appears many of these people are referred to psychological treatment because, well, society doesn't come up with any better option.

But what rubicon33 describes is certainly one way of depression, and I think a common one. But I'd go one step further even: Yes, people lack that little "kick" to get them going and do something entirely. But I don't think that's the root cause.

The root cause, to me, is that this kick has been subconciously "unlearned". Because when people with this sort of depression DO force themselves to do some of these things (and man, do they need to force themselves, with rational arguments and all sorts of tricks), they are not enjoying it. To stick with the example of playing tennis: Non-depressed people come back and say: "That was fun! I powered myself out on the tennis court, maybe I even won, I feel good.". People with this particular sort of depression come back and say: "That was physically, but mostly mentally exhausting. I want to sleep or procrastinate now and reset my thoughts to the baseline of being emotionless."

Disclaimer: Yes, I think I can also kind of speak on this subject. I've been repeatedly diagnosed with childhood PTSD and depression possibly ever since that (which makes it 30+ years); which doesn't mean that I'm not questioning this all the time, because the biggest trick played by depression is to make you think that everything may be just normal sadness/exhaustion/"not trying hard enough" ...).

That's just one of many symptoms you're describing here (loss of interest). For me the main symptom is depressed mood, which essentially feels like someone you cared about a lot died recently.

Anecdotally, the lack of those things are definitely present in myself when I'm experiencing a depressive episode (I am diagnosed with clinical depression): I sleep badly, either not at all or for 12-18 hours a day, I drink far too much, I do not leave my house, and my hobbies either fall by the wayside entirely or I partake in them with no enjoyment or happiness from it.

If you're experiencing those, it might be worth talking to a psychologist or your doctor (to get a referral): you don't have to tough it out. But people who don't have clinical depression also have those issues too, which is why the diagnostic criteria is a little more involved.

For me, a short 3-4 month course of a particular SSRI lets me beat back the worst of it, and Cognitive Behavioural Therapy keeps it at bay. I haven't had an episode in years now

Noticed that both you and the OP mentioned drinking. Just the drinking can cause much of this. Drinking screws up your sleep cycle, which can also cause much of this. Drinking sessions are also time consuming, so you have less time for other things you enjoy anyway. Sure, some things you can do while drinking, but those may not be the things you would prefer to be doing while sober.

These effects fit serious online gaming pretty accurately too.

Screws up your sleep cycle, is time consuming, causes you to not leave the house, makes other hobbies fall by the wayside.

Sure! Though I drink basically not at all when I’m not in a depressive episode. It’s more of a subconscious “self medication” thing, and the symptoms don’t subside even if I’m not drinking sadly.

Seems like a stimulant might be a more logical self medication for depression than a depressant.

A Central Nervous System Depressant and Clinical Depression are two (basically) unrelated concepts. Alcohol is the former. Despite having the same word in them, they are only tangentially related to one another

I was under impression that an alcohol causes a depression.

Alcohol is a central nervous system depressant, which is commonly just shortened to “depressant”. This doesn’t mean it causes depression, it means it has a particular effect on us humans biologically.

That said, it does also exacerbate clinical depression, so this gets confusing quickly!

That's a massive oversimplification which came out of non-scientific 12 step literature and is simply not true in many situations.

I have on many occasions beaten back total anhedonia and a desire to die with a few drinks. It's not an optimal solution obviously, but when your options are limited it is sometimes quite preferable to not drinking.

>I have on many occasions beaten back total anhedonia and a desire to die with a few drinks. It's not an optimal solution obviously, but when your options are limited it is sometimes quite preferable to not drinking

As someone who has suffered major depression, I agree totally that recreational drug use can be helpful in managing some symptoms of mental disorder. I do however feel like moderation is a very important aspect of this which can be harder for folks when they are already feeling down

Many depressed people use alcohol as medication.

otherwise most of them wouldn’t want to socialise at all.

>For me, a short 3-4 month course of a particular SSRI lets me beat back the worst of it

Can you elaborate which one are you using? I was prescribed Wellbutrin/bupropion (along with some therapy sessions) about a month ago and I seem to notice no changes. I'm going to continue to be hopeful but it seems like this wasn't the one for me so just wondering what you were using.

I found medications ineffective, but my last therapist helped me tremendously. If your therapist isn't helping, find a new one. There's no shame in switching.

The most important thing in therapy is relational depth. Doesn't really matter what the method is.

"There is research to support common factors theory. One common factor is the client–therapist interaction, also known as the therapeutic alliance. A 1992 paper by Lambert showed that nearly 40 percent of the improvement in psychotherapy is from these client–therapist variables."

Quote from https://en.m.wikipedia.org/wiki/Dodo_bird_verdict

I am on my second therapist. The first was was a remote therapy based out of Israel. He was great and convinced me to quit my terrible job at the time and reorient my life. His therapy worked to an extent but I never could relay my deep insecurities to him. When I tried to explain deeper concepts to him it nver really registered. I just found myself wasting 120$ per session with no real payback. I continued with him on and off for 5 years before just giving up this year after my father passed away and I gained no comfort from talking to him about it.

A second remote but local(because of covid) therapist was assigned to me as part of this Wellbutrin trial. A total of 10 sessions are to be done with this trial. So far she has only told me what I already know: that I should keep trying little steps every day like increasing my exercise. She gives me little goals but I don't like the fact that since these sessions are 45 mins with no way to extend, there always seems to be a time crunch.

There are tons of therapists in my area with no way to evaluate the differences. This is an expensive proposition as it stands and so I don't know how I will find the perfect one without evaluating each and every different therapist in my area. :/

> If your therapist isn't helping, find a new one.

This has been my experience as well, both personally and through friends.

An important point is that a therapist which works for someone might not work for you, it's rather personal.

Buproprion is quite good at removing false reward loops. Made me really tone down video games. It's used also for smoking cessation. It's quite subtle. The other SSRI/SNRI meds have strong side-effects.

I will say that the effect is permanent. It's rewiring your brain when you use it.

If it's helping you to spend some time on harder but more important self-improvement, then great.

If not, you should consider switching drugs.

I currently take ADHD medicine, which is helping in many ways, but a mixed bag in others.

All the drugs are going to grease the wheels in some way, but you'll have to experiment to find the one for you.

>Buproprion is quite good at removing false reward loops. Made me really tone down video games. It's used also for smoking cessation. It's quite subtle. The other SSRI/SNRI meds have strong side-effects.

That would be a miracle if it did that. My doctor put me on this precisely because it is less strong than other drugs like Adderal. He does not want me going down an addicting road unless necessary. (my summary of what he told me)

So far I have been taking it for about a month although I have missed days here and there and while I try to take it at the same time, sometimes the window varies by +/- 1-3 hrs. I am on the 150mg XR version. What is typical time frame we are talking about before we notice changes? 1 month? 6 months? How long did it take you?

The fact that I am on HN/Reddit/youtube for a couple hrs each day instead of exercising/coding/tidying up/working on my life seem to indicate that no reward loops have been broken thus far. In fact I am slowly sinking in the other direction(but i'm not sure if buproprion is causing it). I have broken another all time record for weight gain despite increasing my exercise regime somewhat.

Was considering stopping treatment after a month if no changes are noticed and wait some time to clear it out of my system before trying something like ayahuasca or psilocybin.

I took Wellbutrin for several months. As mentioned, the effects were subtle for me. The pill isn't going to do the work for you, just grease the wheels a bit. You should probably give it 3 months before quitting.

I'm currently on Adderall. If you have ADHD, it has more benefits than drawbacks in my opinion, and the effects are not as subtle. It does give you focus for tedious tasks, though it's up to you to assure that those tedious tasks are actually important and not a rabbit hole.

Neither drug is going to make you stop browsing Reddit or HN. If you want to reduce browsing Reddit, turn off all the default subs and then subscribe to specialized subs catered to real, specific interests of yours. You will not miss the default subs. HN is only good for about 1 page usually, then it's scraping the bottom of the barrel.

If you want to do more exercise/coding/tidying up/etc. set a 5 minute timer, do at least that much work on that, then reward yourself with some HN. You'll find that starting the activity is the hardest part.

Re: weight loss, you can't outrun your own fork. All the fad diets have a kernel of truth to them, a lesson to apply or discard in your own life. Intermittent fasting is quite effective IME. Besides calorie reduction, it also resets your hunger signals. For me, it got me over this irrational fear of being hungry that I had, and also revealed just how much I was eating out of boredom rather than hunger. Also, you have to pick a problem and focus on it. Mitigate the weight situation, but don't force yourself to fight a 2 or 3 front war.

If you have ADHD, you should be on an ADHD med, unless you literally can't trust yourself to take only one pill a day.

If you have treatment-resistant depression, you can also look into ketamine, either intravenous or now intra-nasal. Pay the price to have it administered professionally, as it's not a good idea to develop a black-market hookup for something so addictive.

which ADHD medicine is good these days? do they raise blood pressure or act as a stimulant? (I guess I'm asking if there's anything better than adderall and ritalin these days)

Yes, there are much better options like Vyvanse or extended release Adderall or Concerta.

Note that these are still stimulants tho. Vyvanse is unique in that its a slightly modified dextroamphetamine (adderall) molecule that gradually gets metabolized by the liver into dextroamphetamine, sort of a "natural" extended release and has a much smoother (side) effect curve. Concerts and XR are just cleverly designed pills that release two doses of plain methylphenidate/amphetamine spaced out, so there's two distinct peaks with a small lull between.

Yes, that's correct. The slow release makes a big difference for a lot of people compared to traditional Adderall/Ritalin

Escitalopram is what I found worked for me. None of the SNRIs did (Effexor and so on), and bupropion isn’t even prescribed where I am for depression for what it’s worth, but I’ve heard some people have decent luck with it, typically as an adjunct with an actual SSRI though.

It took me months to find the right one for me though. Worth talking to your doctor about it if it’s not helping much!

I tried Lexapro 6 years ago when I first attempted to work on this issue. I was prescribed some minimum dosage(I forget what). I will never forget the first day. I didn't feel happy or sad or even anxious. It was as if every emotion was stripped out of my head and instead it was replaced with perfect neutrality. Nothing mattered int he world anymore. I had no thoughts or opinions, just complete neutrality of thoughts and emotions. This also became my most productive week in years. The thought process was literally "Ok I have this task to do, let me do this task, I am done with this task, ok lets do the next task. Repeat until there are no more tasks." No breaks, no distractions were noticed while the task is being performed.

Unfortunately, the side effects were so bad I gave up after a week. Horrible nausea all the time. Such extreme fatigue that i'd sleep 16 hours and still feel exhausted. Not to mention other side effects that are not appropriate to discuss here.

I am considering trying this nightmare of a drug again because I still remember that productivity but man that first experience literally felt like poison was seeping into all areas of my body.

Yeah that absolutely apathy is what kept me alive when I was so close to the edge.

But the side effects (and primary effects!) are also why I only ever stay on it for 3 to 4 months. The sexual side effects alone are enough to impede my recovery, let alone some of the other ones.

So I use it like a bandage to get through the worst parts, rather than a “take every day for years” drug. The “take every day” bit for me is CBT exercises to rewrite my mind, and it’s worked :)

The physical sides for Lexapro at least for me disappeared. I also got the nausea initially. It’s rough, I know.

There are other more modern SSRIs that might be worth trying too, but if escitalopram seemed to work then it might be worth trying to stick it out to see if the sides get better. They usually do

Can you expand on what these CBT exercises are?

I gave up after the Lexapro until this year where I am trying to tackle this issue again with the Welbutrin. I keep reading that maybe ayahuasca or psilocybin might be the miracle key that solves the underlying issues.

I think symptoms of depression are reduced to too few dimensions (these being all disorders names coming from a science which cannot reproduce most of its results).

Imagine Einstein. He can't figure it out and solve the constant problem. Somethings not right. He's not happy, not sleeping well. He's thinking hard.

But then, he takes a pill. Suddenly, no more thinking during bike rides. "I'm just looking around and dopamine rushes in, it's great".

(I'm not discouraging treatment if you have a problem !! Positive feedback loop of negativity can kill you.)

I just mean that if you have high standards you may be less easily satisfied. I do think it's good to be able to step back and really enjoy a walk or music without a care in the world, but I also don't think there's something wrong with people who don't, and instead just focus on their problem. Or even are just looking for a problem or a puzzle interesting enough to solve.

It's all in the context. Sleep is important, you should sleep well. But maybe if you are lunching a rocket tomorrow it's fine to have a problem sleeping. Respect to others is the most basic thing, but maybe if they keep distracting you from work which can improve everybody's life it's ok to say something harsh but effective. And so on.

I don't think you can truly change the world if you sincerely enjoy its current state.

Depression and other disorders are primarily described by being disproportionate responses to stimuli. The astronaut isn't clinically anxious being up at 2am before the launch, but if they were because they had to drive to the post office tomorrow that would be. That's not a world solving problem that's keeping them up at night, it's just trying to live. That's the difference.

Unless there would be something big at the office. Or they hated they job. Or they get burned out because it offers them no life-work balance and space for other activities and relationships outside of it.

In all cases above it's not the brain chemistry that you probably want to fix. But you probably can do just that..

Anti-depressants aren't like a "happy pill". It's not like soma from a Brave New World.

OK, in too much simplified version: you not being content with the state of things may not necessarily be your fault - it may be the things fault.

Of course you can change yourself, all problems are within you, they are created by your optimization function. Apocalypse is not a problem unless you don't want it to happen. Without people who don't make themself content with the state of things right now it's not a nice place to be. But without people who are not content and are trying to fix it it's not getting better.

Just to be too verbose because of sensitive topic: it may be you, it may be chemical imbalance, I'm not saying it's a happy pill and long story short if you haven't experienced happiness in a long time go see a doctor yada yada.

You can be happy during apocalypse when you are making progress towards ending it, you can not like things and accept it. I'm just making a case for unhappiness being the sane reaction in specific contexts.

It's really hard to have a meaningful discussion about this topic without being seen as a murderer while providing a decent information density. Even on HN.

I don't think it's ever the thing's fault. If you're actually depressed about not solving a really challenging problem, this results from a process that works differently in people who aren't susceptible to depression. For instance, maybe you get depressed because you thought you could solve it much more quickly, and you're realizing your self-assessment is entirely wrong, and this starts negative thought spirals that maybe your abilities to do anything are over inflated, and that you'll just experience frustration and negative emotions in tackling anything, and this sucks the drive and enjoyment you used to experience from any of your hobbies.

If you weren't susceptible to depression these spirals wouldn't take hold, you might just say, "huh, now that I've learned more, I realize this is a harder problem than I first thought" and you just carry on.

It is never the thing fault. But it may be the thing fault given your optimization function.

Imagine a kid drowning in front of you (that somewhat happens but on the other side of the world so you can't see directly). You can be unhappy about it, but that's within you. If you don't care about the kid you have no reason to be upset.

Most probably would agree that maybe doing something to yourself to make you less upset about the kid drowning is not optimal. Reality is somewhere between this and somebody living a perfect life and wanting to kill himself.

If you feel persistently low, tired, unhappy, or unable to do things then it's a real possibility.

The PHQ-9 is a pretty standard depression screening questionnaire that you can complete in a minute or two. https://www.mdcalc.com/phq-9-patient-health-questionnaire-9

This doesn't control for the fact that the world sucks now, does it? I read a few months ago that ~25% of young adults had thoughts of suicide in the past year, so I think it's safe to say that the causes are more external than internal at this point.

Disentangling pandemic effects from "normal" life is complex but overall in the US suicide rates are actually down for 2020, though slightly increased for younger Americans. The trend in the US was upwards into 2019 so these are positive developments.

It is very difficult to properly assess 2020-2021 survey data both because the "you should be depressed" messaging is very strong in the media and the bias in who responds to surveys is complicated by the pandemic.

I am a Canadian and we saw an enormous drop in suicides, 30+%, in 2020 despite survey data (and wacky conspiracies) to the contrary.

I don't think it is "safe to say" much of anything about suicide rates or individual motivations, it is a complex issue.

> the bias in who responds to surveys is complicated by the pandemic.

Many people have lost family members and been pushed into poverty. It is incredibly callous to think mental health can be discretely measured without accounting for the environment.

Suicide is not a quantitative measure of mental health.

If the claim that "Suicide is not a quantitative measure of mental health" means that such large fluctuations in the suicide numbers across many jurisdictions with differing underlying rates can't be used to inform any opinions about the impacts of the pandemic on mental health then I emphatically disagree.

I don't know who said you can measure mental health without accounting for the environment, I never made that claim! I literally said "I don't think it is "safe to say" much of anything about suicide rates or individual motivations, it is a complex issue."

> Suicide is not a quantitative measure of mental health.

I'd say a population with high suicide rates is more afflicted by mental health issues than one with lower rates. What would you say?

No, it is down to policy and culture.

Simply put: I could purposely crash my car and it would not be counted as a suicide or homicide.

While there are a lot of reasons for that to be the case, my point is the numbers are not representative of our current position.

A more holistic approach measuring alcohol and drug abuse, domestic violence, social media sentiment, and workforce participation.

Unfortunately, all of which are indicating that the majority are collectively suffering.

People might adjust fairly quickly due to the hedonic treadmill

"Lottery winners and accident victims: Is happiness relative?"(1978) https://psycnet.apa.org/record/1980-01001-001

It's probably more likely that the internet is amplifying every problem in the world and since young adults grew up with it, it's more integral to their lives.

Additionally, there seems to be a stigma attached to not caring about a particular event, especially if doesn't affect you, all because of the slippery slope argument which is a fallacy.

> This doesn't control for the fact that the world sucks now, does it? I read a few months ago that ~25% of young adults had thoughts of suicide in the past year, so I think it's safe to say that the causes are more external than internal at this point.

How did you come to think depressions' cause must be internal ?

What is the baseline?

as someone with mental health issues going through a rather prolonged and winding down period, i’ve taken this before. just got my high score!

going to bring this up with my therapist tomorrow

I am increasingly confident I suffer from depression, rather than just being generically miserable.

How do you deal with the trust issues posed by that questionnaire? I have suicidal thoughts most days, but I'm concerned that revealing this to an NHS doctor would quickly result in my freedom of choice on what happens next being taken from me. Seems like one of the few cases where US healthcare (where you are explicitly a customer as well as a patient) has some advantages.

Not a doctor but have experienced something like what you're describing. It is important to be open with your doctor about this stuff because it allows them to accelerate getting you help. Differentiating between suicidal thoughts and intentions (the former of which I had, the latter I did not) made me comfortable enough to have the conversation.

Really though, seek help. It is unlikely you'd lose choices (eg be sectioned) if you're asking for help and engaging with that help.

That's a good point - thanks. "Thoughts" rather than "intentions" is definitely more aligned with where I am. Part of the trouble for me and presumably a lot of people is untangling those things - for example, would my thoughts be intentions if not for having a spouse, who I could never imagine hurting in that way by leaving? Moreover, does the mere presence of that kind of "blocker" represent a positive sign?

I pick at this stuff in my own head all the time, and just don't have enough confidence in doctors to believe they could tell me anything new. Being able to skip straight to pharmaceutical or other non-talking solutions via a disclaimer would probably mean a lot more people like me would seek help.

> Being able to skip straight to pharmaceutical or other non-talking solutions via a disclaimer would probably mean a lot more people like me would seek help.

Antidepressants are strong stuff. Some years ago I hit a bit of a snag and went to a doctor and got just this, a prescription after five minutes of talking with helpful advice like "get a girlfriend" or "study something else". Stuff really worked... except in the wrong direction. Not an exception either, common enough they put "suicide" as a side effect in the fine print. I think if you're gonna take something like that you need some kind of feedback/monitoring and test different drugs until you might find something that works right. A hands off fire and forget prescription like I got likely won't work for most people.

Yes, the presence of a blocker like that is a good thing. What ifs aren't the most useful thing though.

GPs have been enormously helpful to me with this stuff. Most are very understanding. If you can do an online appointment booking that might help too - so the immediacy isn't an issue so you can write the appointment reason very clearly and revise it as much as you want before hitting the button. Otherwise, tell the receptionist you'd like a phone appointment (for the distance that gives psychologically) and that it is for a mental health issue. The diagnostic criteria for depression are fairly easy to satisfy - it is mostly about low mood for 4+ weeks. Keep details to a minimum you need to get a prescription but be cooperative if they probe.

Whatever you do though, don't just suffer. Tell your spouse how you feel too. Get some help.

Involuntary admission works the same way in the US.

I have kinda the same problem. I've had depression for a very long time - stable, but consistently declining. I get the "... or I could just kill myself" xapata mentioned a couple times per week and the reasons I don't are basically "that sounds like work" and "that would make my mother sad". Which aren't exactly good reasons, I know, but so far I've done very little actual self-harm and I very much don't want to get involuntarily admitted. I really would like to get help to deal with depression. I've battled it out alone with it for 15+ years and I'm not exactly winning that fight. But- anyone that's qualified to offer that help is pretty much legally required to admit me if I answer their screening questions somewhat truthfully.

Damned if you do, damned if you don't.

Procrastination isn't necessarily a sign, but if you're procrastinating on things you usually love (hobbies) then, yes. Talk to a professional.

Depression is surprisingly common. Most people kick it after a month or so of meds (the individual in the article clearly has chronic depression).

Yes - those things are closely related to some of the diagnostic criteria used by some of the tests for depression. The remission of those symptoms is a quite a good signal all by itself.

See for example https://www.medscape.com/answers/286759-14692/what-are-the-d...

And consider “ Diminished interest or loss of pleasure in almost all activities (anhedonia) “

— his ability to enjoy guitar for its own sake is a great sign.

And “ Sleep disturbance (insomnia or hypersomnia) “

…he addresses that directly.

But the presence of those symptoms doesn’t by itself mean that a major depressive episode is the best or only diagnosis.

But having some of those symptoms is enough to indicate you should talk to a medical professional, as they are very troubling symptoms.

Yes, they can be. Self-diagnosing isn't a great idea; lots of non-depressed people have some symptoms of depression. It would probably be a good idea to find someone to talk with though.

Where "someone" is a therapist or counsellor. They can refer you on to someone who works with pharmaceuticals if necessary, but there's a lot to try before going that route.

Heads up, ‘There is a lot to try before going that route’ is a medical opinion that is hard to notice. Exactly what the treatment plan would be and in what order is entirely up to the doctor and sometimes (often) the best thing that works is the actual drugs.

I’m just conscious of this because I’ve seen this argument used to justify delaying actual treatment in favour of ‘alternative medicine’.

True, yes, but nothing you hear in a CBT session should be super surprising. It may help you see things in a new way or understand the motivations of the other people involved in your life situations, but they're not going to tell you sleep with crystals or wear a magnetic bracelet or something.

Basically the counselling/therapy part of the process would be identifying if there's a "real world" root cause to address ahead of going the pharma route and facing potential side effects, and/or the reality of having to go off it later and immediately regressing because the root cause hasn't been fixed.

In any case, I'm obviously not a doctor; neither this post nor the GP should be construed as medical advice.

I wouldn't rely on answers from HN. I don't have depression, but I do have anxiety, and professional help changed my life. It would not hurt to get an evaluation if you feel like something is off.

It's a very common condition. I think most depressions are mild or not invalidating, so people are functional, and they don't really seek treatment.

Also the "just do it" mentality is very damaging to admitting people can be depressed.

Yes. When you have depression you get basically nothing done. Even things that used to be fun aren’t fun anymore. You are miserable if you do something or nothing.

Well now I wonder what the side effects are. Because if they are not serious I wouldn’t mind taking this drug just as a matter of course.

Procrastination, not enough sleep, alcohol and no hobbies sounds pretty normal for most people.

Lately I've been reflecting on the source of my low feelings and I have determined that in my case that alcohol is playing a key role. It is a de-motivator and its effects are pernicious in that it causes the user to become unaware that it is responsible for exacerbating depressed moods even after feeling intoxicated has worn off. I drink responsibly but think its time to cut it out to see if I feel better.

I think the criteria for a diagnosis is if it interferes with your regular day to day life (ability to hold a job, relationships, e.t.c)

> “The treatment, known as Stanford accelerated intelligent neuromodulation therapy (SAINT) or simply Stanford neuromodulation therapy, is an intensive, individualized form of transcranial magnetic stimulation. In the study, remission typically occurred within days and lasted months. The only side effects were temporary fatigue and headaches.”

> “Twenty-nine people with treatment-resistant depression participated in the study: About half received SAINT, and the rest underwent a placebo procedure that mimicked the real treatment. After five days of treatment, 78.6% of the participants in the treatment group were no longer depressed, according to several standard methods of evaluation. “It’s quite a dramatic effect, and it’s quite sustained,” said Alan Schatzberg, MD, the Kenneth T. Norris, Jr. Professor in Psychiatry and Behavioral Sciences, who was a co-author of the study.”

Makes me wonder what percentage of the placebo group improved?

> The transcranial magnetic stimulation treatment currently approved by the Food and Drug Administration requires six weeks of once-daily sessions. Only about half of patients who undergo the treatment improve, and only about a third experience remission from depression.

Within four weeks after treatment, 12 of the 14 participants who had received the treatment improved, and 11 of them met FDA criteria for remission. In contrast, only two of the 15 participants who had received the placebo met the criteria for remission

From the article further on.

Considering we are chemical based, I wonder how of it is the serotonin receptors are plugged with LSD, an effect similar to SSRI's. https://edition.cnn.com/2020/02/27/health/lsd-overdoses-case...

But what about other chemicals, Glycine contributes to an increase in 5alpha Reductase which helps reduce Cortisol one of the stress hormones. It can be used in place of sugar in hot beverages and food, how much does stress contribute to depression? https://en.wikipedia.org/wiki/5%CE%B1-Reductase#List_of_conv...

And then there is Glutathione which increases light sensitivity, could this help reduce Seasonally Affect Disorder (SAD) also known as the winter blues, knowing that it also helps management of ROS, peroxides, lipid peroxides and heavy metals? Glutamine, N-Acetyl Cysteine and Glycine help to increase Glutathione in the body.

I wonder if fMRI has a similar effect on the brain to homogenising milk, namely it softens the fat walls in milk. Is fMRI having an effect in the brain or in the vascular system with plaques that contribute to atherosclerosis, because induction hobs or magnetic induction reduces inflammation https://peerj.com/articles/929.pdf does this demonstrate that depression is caused by a variety of factors not just one's linked to serotonin even though serotonin plays a part with the immune system?

The two mentioned in the article met the FDA definition of remission. It doesn’t say, how many improved in general. This is important specifically since the sample size of the trial is small.

I agree both endpoints are interesting-- but arguably remission is more important of an outcome measure than improvement.

But remission is defined by the same measure. It’s just an arbitrary threshold on the HDRS.

Sure. And improvement is doubtlessly confounded more by the placebo effect. Still, both are interestink.

It's the important & useful of the two endpoints they measured. Anything will have a positive effect on depression if it comes with a lot of high-tech vodoo and people in lab coats. Only it won't last and it will the "yeah, I guess I'm feeling better"-level of improvement.

> Only it won't last and it will the "yeah, I guess I'm feeling better"-level of improvement.

Who says it won't last? Most depressions actually do get better by themselves.

How do you think humanity has survived so far?

(Most, but not all. And even if it eventually gets better without meds, there was still a lot of suffering.)

It's quite possible humanity has survived because most people never get depressed. You need to be quite clear about definitions to have a meaningful conversation on this.

Unfortunately your genes don’t care about whether you’re happy or not beyond your gene’s needs for survival and reproduction.

Yes. And given the prevalence of continued prevalence of depression, there might be some evolutionary benefit for the genes that also cause depression.

No clue whether it's the depression itself, or whether that's just a side-effect of something else that's useful.

Maybe. So please ignore the part where I speculate about evolution, if you want to.

Empirically, most clinical depressions get better by themselves today.

Similarly, most alcoholics improve by themselves.

(Of course, effective treatment is still useful!)

Does this also imply the possibility of the inverse, magnetically making people depressed?

This reminds me of Greg Egan's creepily effective SF story "Reasons to be Cheerful", which is online here: https://www.utilitarianism.com/greg-egan/Reasons-To-Be-Cheer...

How happy would you choose be if you could consciously decide how happy to be?

This is a great comment. I've always been a little uncomfortable with the thought of this magnetic treatment in a way I couldn't put into words and this nails it.

I'm willing to trust, perhaps naively, that everyone is getting the same Prozac tablets. But how does the skill of the practitioner and maintenance of their magnetic treatment device affect outcomes? It's almost like a surgery, but I'm not sure who's actually been trained to perform it.

Which isn't to say someone shouldn't do it, just my own feelings based on limited understanding. Perhaps if I knew more I would have greater faith.

The trial used fMRI data to find a cortical area that has functional connectivity with the DLPFC. That area is then targeted with a neuronavigation system (similar to AR), that helps the clinician place the TMS coil at the right spot and the right angle. This in addition to the magnitude of the pulses being based on the patient's threshold (e.g. minimum amount of stimulation that causes motor movement when used over the motor cortex) is what is meant by "personalized".

It's also of note that the treatment takes place over multiple days and there's multiple sessions in a day. During that time, patients are continuously evaluated. This trial was also only used on patients with treatment-resistant depression (i.e. have tried many different medications and forms of therapy, some included ECT) and were screened as such. From my understanding, the treatment was explored as a "last resort" for those that could find no other medical relief, but this obviously has further implications.

A whole lot of treatments end up refined with time.

The FDA approved treatment is "aim at the middle of the dorsolateral prefrontal cortex". Getting more activity and connectedness improves its regulation of overall emotional activity.

This research implies that aiming instead slightly differently and a different dosing regimen may be more effective.

This is no different from any other medical treatment, where we find refinements in how and where to apply basically the same treatment to get better results.

Yes. Treatments are simply implementations of science technology at a particular time.

To get some perspective on iterations of treatment, read this account of the work of August Bier.

He pioneered spinal anesthesia, something used all of the time today for epidurals during childbirth.

His experimental treatments he both performed and had performed on him by his assistant will, at the very least, raise your eyebrows.


There are drug recalls: https://www.fda.gov/drugs/drug-safety-and-availability/drug-... which would invalidate your assumption about Prozac tablets.

Magnetic therapy makes me feel sick to my stomach for reasons that have for long been unknown to me. I'm more comfortable with the idea of undergoing electroconvulsive therapy than something that involves magnets. I'm not sure why it bothers me so much, but it does to an unusual degree.

Human emotional responses to wireless technology, even before the invention of said technology, are very interesting. Check out the wiki page for James Tilly Matthews.

Yikes, hope I'm not a hatter like this dude. Thanks for sharing, lead me to discover the Travels Through Time podcast and listened to this episode: https://www.youtube.com/watch?v=d7GdAHr7ZHU

Odd coincidence. The link to “pneumatic chemistry” in that article is purple because I was just reading about the history of bismuth.

It seems like a… blunt instrument.

That’s what gives me pause.

I concur with this, and the concern that you don't just get something for free. What is the actual mechanism at play here?

Do you have the same feelings about radiation therapy for cancer?

It's all a little freaky if you think about it: even in evidence-based medicine, a whole lot of it is people making qualitative determinations and squishy adjustments to treatment, and undoubtedly getting it wrong a whole lot.

Then again, the stuff shows benefits in trial, and presumably we get most practitioners trained up and doing the thing that's the standard of care well enough...

There might be the perfect amount of paracetamol to take to treat your light headache.

But in practice people just take two 500mg tablets and call it a day. Works well enough most of the time, even though it might be 'wrong' in some platonic sense of the word. (Eg you might have been helped enough with a slightly lower dose. Or perhaps 1250mg would have been better and suppressed slightly more of the pain. Who knows?)

There are plenty of doctors that rather die than treat their cancer. There was even a "recent" HN story about it. The motivation is that for a nasty one, the treatment is often worse than the disease, and they rather spend their wealth and to easy their pain and enjoy their last months of living rather than going through a very hard process that might not work, might leave them in an not that good state.

No, it's a very different situation since radiation therapy has such a long history at this point.

I'm just not sure what the margin for error is, the failure modes for this magnetic therapy, or what makes a good magnetic therapist.

Not a reason to stop developing it though.

Magnetic treatment has a long history... we've given billions of MRIs, no one's grown a 3rd arm.

They stimulate activity in a precisely chosen part of the brain. There is no inverse. They could stimulate a different part. In fact, they use the motor cortex to calibrate the stimulation level to be the lowest that produces any involuntary movement. I imagine it must be interesting for the subjects.

Any study can only imply the outcome of what was observed. The techniques they used required an MRI machine so you aren't going to see magnetic fields wherever you go.

For a treatment-resistant condition, 50% success rate can be worth the effort.

Hell, 5% is worth the effort if it's little enough effort or the condition is severe enough. 80% is incredible if it holds up.

Not if it utterly ruins the remaining 20%. Or results in Lewy-Body Dementia in old age, or, or.. That's my concern here.

I wonder what results you'd get if you tried a treatment which was literal torture...?

Eg. "We'll poke this red hot poker into you 10 times to cure your depression"... Many painful screams later... "So, is the depression any better now, or should we do more treatment?".. "Yes, yes, I'm pretty much cured!".

How can we be sure that this 'torture effect' isn't whats being measured here? Especially when the treatment appears to have unpleasent side effects, and the success of the treatment is measured with patient feedback...

Wouldn't the patients just opt out of the trial rather than continue and lie to the researchers? Nobody's being forced into it

You can't assume that.

Part of being depressed is you don't even have the will to resist being treated in a way that you don't like.

In fact, I'd say that feeling powerless against conditions that you don't like is the core of what depression is.

It's why someone who is depressed doesn't feel like doing anything, because they feel like no matter what they do nothing will ever change so nothing they do is ever worth the effort.

It doesn't need to be that intrusive.

Just mildly uncomfortable .. for a period of time longer than one would be willing to tolerate.

Something like being at the dentist when you have many cavities in your teeth.

You can tolerate one or two sessions. But the idea of doing it every day for two weeks straight is unbearable enough that you decide on the third day to report feeling well.

The article says 2 out 15 improved in the control group.

Likely more than 2 of 15 improved. The numbers to compare are 2 of 15 remission vs. 11 of 14 remission-- not <<unknown>> of 15 improved vs. 12 of 14 improved.

> Makes me wonder what percentage of the placebo group improved?

For future reference, assuming this is a clinical trial, data from clinical trials is available online. This is the kind of statistic that you'd be able to find.

But it must be difficult to do so, or you would have done a lmgtfy link or comment like "Just search the study title and look at table 12."

> Within four weeks after treatment, 12 of the 14 participants who had received the treatment improved, and 11 of them met FDA criteria for remission. In contrast, only two of the 15 participants who had received the placebo met the criteria for remission.

>>In contrast, only two of the 15 participants who had received the placebo met the criteria for remission.

Hey! I didn't under go SAINT TMS specifically, but I have undergone TMS therapy. Reading this article I'm not sure how different what I received actually is compared to SAINT, but TMS absolutely changed my life. I was referred to TMS after a rash of different medications and years of talk therapy fell short on relieving the worst of my symptoms. Many of the benefits the patients in this article discuss are ones I received as well. I really do suggest it to anyone who is able to access it and suffers with severe depression.

Really happy to read about your positive experience. TMS changed my life also. It ushered me out of a nearly 5-year depression.

It was interesting to talk to the technicians/clinicians about how they came to be working at a TMS clinic. Several told me they'd been working in mental healthcare for decades, and were excited to work with TMS because it was the only thing they'd ever seen be truly effective in treating severe and persistent depression. One told me she had been helping patients through the 6 week program for three years and had not seen it fail to help a single person.

When I read the paper for this study it brought tears to my eyes. To think that it's possible to apply a lasting treatment to someone stuck in their own personal hell over the course of five days, and to have the effects persist for six months, is practically a miracle.

My treatment was over two years ago and I have not relapsed. There is hardly a day that passes where I do not feel deep gratitude for that burden to be lifted.

Wow it's so great to hear from another person who had a life changing experience with TMS! The clinicians were really blown away by how quickly the TMS started to help me and even though it's been over two years since my treatment I really do feel as though it is still helping me now. The clinicians that I talked to at my clinic were similar in their experiences. It really does drive home for me how debilitating depression actually was for me and still is for so many people. I spent years taking all the "right" steps to feel better and following advice from different doctors, and I still was often overwhelmed. I am happy that now when I use the skills I had built up over years with my therapist they are a lot more effective.

I have some questions if you don't mind:

Was it expensive?

Are there any downsides?

Do you think TMS is, like psychedelic therapy, potentially useful for people without depression (i.e. the "betterment of well people")?

Re. How expensive it is. There are cheap home-use alternatives to TMS. For instance tDCS.

Here is a great comparison of noninvasive brain stimulation techniques for depression treatment: https://www.bmj.com/content/364/bmj.l1079

A company that offers tDCS as a home treatment for depression can be found here: https://flowneuroscience.com/

Very interesting. And there are tDCS home kits for $149, e.g. https://apexdevice.net/shop/apex-type-a-4ma-std/. This is low cost enough that I'm willing to give it a shot. Worst case, I end up with a decent DC current source that I'm sure I can find a use for at some point.

Okay, sounds like some people trying this at home have had seriously bad side effects. So will definitely have to do some reading before giving this a shot.

How so? tDCS is considered very safe. Here is a good review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007190/

Hi! TMS is at a baseline very expensive. Luckily(hah, sort of) because I had both suffered terrible side effects with several medications and I carry a sustained diagnosis from a very young age that was documented as being massively detrimental to my ability to function, my insurance was willing to cover the treatment. The head coordinator of the program actually advocated very heavily on my behalf for me and spent a lot of time working with my insurance to get me covered.

The main downside of TMS is simply that you have to be fully dedicated to the treatment. For six weeks I had to go Monday through Friday to a special clinic that was a half an hour drive from my house. This was a point that they brought up repeatedly in my interviews to get the treatment, so I think it must be common that people decide that it is too much dedication. For me though, by the time I was interviewing to receive TMS I had really tried everything and I was absolutely desperate to follow any path that would offer relief from my symptoms. I had gone through multiple medications, had been in talk therapy for several years, tried CBT, DBT, self medication, meditation, yoga, exercising three times or more a week, different diets, spiritualism... Really the works. I could sometimes stave off my symptoms but eventually I would suffer a huge crash and totally burn out again.

One of the other possible side effects is also seizure during treatment(very rare) and because of this they ask that you abstain totally from substance use during the time as it can lower your seizure threshold, which I agreed to happily. While the idea of having a seizure was scary, I had already experienced so many horrible side effects from medications that didn't even alleviate my symptoms I was willing to try anything.

I am not an expert in the field but I do think that there is a lot of use that could be gained for any person who decided to try TMS, for me some of the things I noticed was that my brain fog started to lift and suddenly I was able to learn much more quickly. I started practicing languages and instruments to really help foster this growth in my brain. The TMS helped me break the patterns of my mental illness and start forming healthier ones...I really do credit it with saving my life.

I did it too. Didn't seem to help me unfortunately. Really would like to try SAINT when it's approved.

I'm sorry it didn't help you <3. I hope you get the chance to try SAINT!

Looks like it is just more tailored to your particular brain neurocircuitry and give more pulses but instead of in 1 session over ten small sessions in a day. Sounds like it only makes sense that this works even better!

I've been dealing with depression, or rather, a couple of months with productivity where I really work my ass off producing great stuff, then have an as long downtime where I just manage to get by. Any choir was tough to start doing and completing. After being diagnosed with both ADD and ASD.1 I also was diagnosed with Bipolar 3/4. Did not even know they existed but they trigger these hypomania periods. Turns out that hypomania is pretty good for working in IT and you can hide and get by the rest of the year. On the other hand, now that when I feel that the depression is completely gone, I discover that I'm entering a hypomaniac period. What a way to ruin all the fun. The awareness around it is quite low from where I'm from sadly. I wonder how well SAINT would affect.

You are not alone. I also have been going through something similar. I recently quit my job to work full time on my side project. I am financially secure for another year. I am very energetic for few days, I work my ass off and ship stuff. But after that I have these periods where I just can't do anything. It is hard to get out of bed. I feel like I am never going to make it with any of my projects.

I have been to a neurologists in the past multiple times and completed multiple courses of medicine. But those medicines I took had really bad side effects. And I realised the more I used them the more I was dependent on them for a normal mood. Also my brain felt foggy while working when I took them.

I do take time off after a few days of working but that alone does not help. This is a cycle. Planning on going out daily and exercising, eating more healthy and having a schedule with less screen time. Let us see how it goes. These things seem trivial, but I have never them for more than a month continuously. I want to give them a try this time like my life depends on it.

I can totally relate to your experiences.

Writting about myself and what seems to have helped me.

Have been on medications for two years (getting off of them now), and in therapy for a year. Likewise, I had (or have) troubles with feeling stagnated/unmotivated after bursts of productivity and motivation.

The key insight was that creativity and productivity does not come without cost. I used to overwork myself and my body. After "feeding" the intellectual part of me, the other parts became "hungry".

The solution for me is to have breaks, even when I am in the state of flow while doing something productive, and use that energy to work on the dull activities that are required to keep me healthy - physically and psychologically. The stream of consciousness style of journaling helps me as well - it helps the root cause of my bad feelings show themselves, sometimes in a subtle way.

What you may want to have a look at is Active Imagination[1], it comes from Jungian analytical psychology. I find it really helpful.

Good luck!

[1] https://en.wikipedia.org/wiki/Active_imagination

The key here is "work my ass off". Even if you want to work, limit that part off and put that energy into training (like swimming e.g.). I know that sounds dull, but dull is better than not getting up from bed. If you are going to make it without the meds to stabilize, do limit the time you work in a manner that you don't fall in those cycles.

A well put metaphore I've heard is that you got a set of forks which you use daily. Make sure you don't run out of them. The problem is that it feels so great just using them all when you get a new clean batch after a couple of days of downtime..

Good for you that you are aiming for stability. Setting a structure and planning for mentally tough parts of the day (like social events) and never parting from that can make a total difference in life quality. It would for anyone obviously, but with living on some spectrum it's a life ingredient. Yeah, it's tough, and yes your life (as in with great life quality) depends on it.

Bipolar 2 here. I didn't get diagnosed until I was in my late 20s. I just thought I got carried away with things sometimes. I got on lamotragin a few years ago and I've been Even Steven since, but I do sometimes miss the productivity of the mania. Not worth the downs though.

I'm curious what this treatment would do to people who are "not depressed." What's the downside?

Perhaps the next Timothy Leary will have an fMRI in the basement and a line of customers running down the street.

I remember reading a while back a article on how a US military research group was looking at improving focus and some particular test scores using TCS. Which sent me on an investigative rabbit hole of people that are using it at home in a diy manor. So I don't think you are too far off!

A quick google pulls pack a couple of interesting links: A subreddit https://old.reddit.com/r/tDCS/ and an article https://www.wired.com/2014/05/diy-brain-stimulation/

Years ago I found the video by Dr. Robert Sapolsky[1] to be a good introduction to the topic of depression. I also suffered a major depression of my own about six years ago. It was a horrible time in my life.

[1] https://www.youtube.com/watch?v=NOAgplgTxfc

Cost (and availability/wait time for nations with public healthcare) are a concern. I know several people who received conventional TMS for 30 minutes a day for six weeks. That cost them, with insurance, about $1500. It was effective for an average of six months. This treatment is an order of magnitude more time spent in the machine, even if over a shorter period. What will it cost? Will it be accessible to those who need it?

Depression has an enormous economic impact. Fatigue and pain (depression related symptoms) are some of the most common reasons people can't work in the wealthier part of the world. If the treatment costs $4000 dollars yearly and makes the difference between debilitating depression and functioning taxpayer that is self financing for the public healthcare.

Not to mention the personal suffering.

Psychedelic mushrooms are far less expensive and have a similarly effective result in similarly sized trials: https://www.hopkinsmedicine.org/news/newsroom/news-releases/...

> If the treatment costs $4000 dollars yearly and makes the difference between debilitating depression and functioning taxpayer that is self financing for the public healthcare.

That's a good bargain for people who pay out of pocket as well.

There are cheaper and easier to use brain stimulation treatments for depression than TMS. tDCS, that uses current instead of magnetic fields, might not be exactly as effective as TMS but is much more accessible and can be used at home. It stimulates the same area of the brain as TMS (DLPFC).

Here is a great comparison of noninvasive brain stimulation techniques for depression treatment: https://www.bmj.com/content/364/bmj.l1079

A company that offers tDCS as a home treatment for depression can be found here: https://flowneuroscience.com/

$1500 is cheap. I know people who’ve been receiving therapy 1 hr/wk plus medication for years. Even here, where the medical costs are a lot lower than in the US, that’s probably €5000/yr, and that excludes the indirect costs of depression.

70% of Americans have less than $1,000 in savings.

weird how people can often become depressed due to actual real-world experiences like grief or loneliness, but slap a magnet on em and they can go into remission.

Makes you wonder whether they'll go into remission for a while and then slip back into depression if the environmental factors are still there. I guess if it can knock you out of a depression where the trigger is no longer present but the trauma persists, that's incredibly valuable, even if the mechanism seems very strange.

> environmental factors

Actually being depressed can worsen environmental factors. Depression can make it hard (or impossible) to maintain work, relationships, hygiene, sleep, diet, and exercise. Losing the things can make the depression worse.

Yeah I know - it's a vicious cycle. I meant in cases where the depression trigger was an event like a death in the family, but where the person managed to keep it together despite their depression. In those fortunate cases, the only problem that needs solving is the person being "stuck" on a trauma - not a self perpetuating cycle.

What you're describing sounds more like grief than depression. While the profound sadness that comes from loss can certainly manifest itself in ways that seem like depression, they are not the same thing.

Grief can certainly morph into depression.

At one point I was in ER close to death from large clot. Doctors had been treating my clotting disorder with Prozac. Since clearly I was just making up symptoms due to my “depression”

Anyway Doctor was explaining the damage to lungs and odds of survival, but I was totally chill about it thanks to Prozac.

Plus side doctors finally believed me that I wasn’t making up stroke symptoms.

Sometimes depression has a real cause that needs dealing with.

Depression can be acute or chronic but everything about what you think or feel is still just chemistry and chemistry is just physics. It's a bit surprising it can be treated with such a blunt instrument as external magnets but then again we use electroshock with some success.

Yeah I am not against this treatment, but I do think sometimes the mind--body relationship isn't treated very well in modern medicine.

Every mind issue is also a brain issue, and so there is no actually boundary between the "real you" and an ailment --- it's an arbitrary division influenced by social norms.

I am no expert but I understand medical ethics is more trolley problem type stuff than issues like this. Similarly is the fact the many psycological ailments are highly culturally specific but the DSM just sort of assumes American context and doesn't go into this.

It’s not just environmental factors that cause chronic depression. Sometimes the environmental factors are the “trigger” that start depression in a person predisposed to it.

Case size 14, control size 15. It's 2021; you shouldn't be able to publish a psychology result with statistics this weak.

Not true. A strong effect can be meaningful for small n. This is well known from power analysis: https://statisticsbyjim.com/hypothesis-testing/sample-size-p...

I also think middlebrow dismissals are discouraged on HN: http://www.byrnehobart.com/blog/why-are-middlebrow-dismissal...

Under the null hypothesis, a difference this large is still extremely unlikely for a group this small. Sometimes, counterintuitively, you don’t need a huge group.

Yeah, this is a fairly standard size for an early trial.

Trials cost money. Even if this is a lucky outlier and it turns out to be no better than the placebo in a larger trial, having a decently strong positive result can hugely improve your chances of getting the money (and interest) needed to run a larger trial.

But it’s worth realizing this small of a trial size likely means there’s a long road to widespread use

Sure, but at that point the complaint is in either the journalism being misleading (implying it's "coming soon" in a layman's use of "coming soon"), or our outsider view into internal messaging is misunderstanding the claims (if this was written for people familiar with the field, "there's a long way to go" is safe to assume as base knowledge, which outsiders may not have).

tl;dr yeah, but everyone knows that / science journalism is terrible.

The same could be said for a massive trial with a small effect.

I am curious what the proper size group is for such dramatic results to make it publishable? The results are quite dramatic, it is not a slim success.

That’s an aggressive take for someone who hasn’t bothered to consider the effect size when claiming to know statistics better than these authors.

The heart of the middlebrow dismissal is the assumption that the dismisser understands a field/industry better than a person who's spent their entire adult lives studying it.

I'm surprised nobody's linked to the recent time this was on HN [1].

Having tried TMS pretty extensively, I do not think this will help me, but I am hopeful that it might prove useful for others.

[1] - https://news.ycombinator.com/item?id=29562785

Which machines did you use for your rTMS? Or did you do something besides rTMS of the clinically available noninvasive types[1]?

[1] https://www.uptodate.com/contents/unipolar-depression-in-adu...

Looking it up, they used NeuroStar machines, though (obviously) not for 10 hour stretches.

I've been dealing with depression for over 15 years. I can only hope that this becomes available to the masses.

It is available to the masses, or at least similar techniques. For instance, check out tDCS: https://pubmed.ncbi.nlm.nih.gov/33706656/

Here is a great comparison between different noninvasive brain stimulation techniques for depression: https://www.bmj.com/content/364/bmj.l1079

If you haven't had results from medication, there are a couple of new drugs on the market now that are indicated for treatment resistant depression.

Have any details? I have a close friend with treatment resistant depression.

There's two SSRI-like drugs called vilazodone and vortioxetine that are indicated for it, as is esketamine.

There are also a few antipsychotic-like drugs that are used at low doses for antidepressant effects along with other antidepressants, but I'm not sure if the newer ones are indicated for depression, or if the newer ones are just reformulations of existing medications. It looks like there's a newer olanzapine combination on the market.

any examples i can look up?


Note that this is an enhancement to an existing therapy. Depending on where you are in the world and the healthcare providers you have access to, the existing therapy called Transcranial Magnetic Stimulation (TMS) may be an option.

Some TMS clinics are offering the SAINT protocol off-label. Not covered by insurance of course, supposedly runs around $6k.

There's a used TMS machine on ebay for $8k (and $70k) and clinical instruction videos on YouTube. Could be a good side hustle haha.

Unfortunately for SAINT it looks like you also need fMRI to correctly target the therapy...that's going to be a bit tougher to DIY.

Just start the process, get the fMRI scan, pay for that, and request a copy and bail.

For those taking this seriously: fMRI requires careful presentation of stimuli and a complex analysis. It’s not just a scan. I doubt you can get that at Scans’R’Us.

Can you please provide some links to said providers . I wasn't able to find any. Just some that mention it

This one in Georgia: https://rejuvenatetms.com/blog/

You can also search this TMS FB group https://www.facebook.com/groups/285541688306686 for "saint" and find other people's experiences.

Edit: Apparently, the clinics that claim to be offering it might just be doing something that is loosely based on what is publicly known about the SAINT protocol. Dr. Nolan Williams hasn't released full details, so it's not possible for clinics to replicate it exactly. This clinic https://www.cambridgebiotherapies.com/accelerated-tms/ talks about how they've tried to reverse engineer the protocol at the bottom.

Pretty sure it's already available.

How so? Where do you register?

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