Is everything you think you know about depression wrong?
January 8, 2018 5:22 AM   Subscribe

 
There is some interesting stuff here but the style of the piece seems to pose a kind of binary opposition between “brain chemicals” and “environment”/the “old story” and the “new story” that isn’t is particularly helpful. I assume the book is more nuanced than the article, but I would have liked to see the article more loudly emphasise that some people should indeed take antidepressants and anti-anxiety medication, that working out what they can and should do in addition to support their recovery is pretty complicated and the science is tentative, and that the relationship between therapy and medication and larger questions of lifestyle and social support is far too complex to be boiled down into “not chemicals, environment” or “here are seven simple steps”.

No humans are machines with malfunctioning parts, clearly; we aren’t machines, we make choices and have emotions and our bodies respond to what we do and feel as well as shaping it. It’s still true that some humans—for example, ones with diabetes— have organs that are not functioning efficiently to meet their needs and that there are chemicals they can take which, in combination with other choices and support (eg around lifestyle, diet, exercise etc), will help with that. The connection between what we do and feel and how our bodies respond seems to me to be irreducibly complicated; “just take these pills/ this injection” is not great as a response to either diabetes or depression, but neither is “forget the medication, just change your whole life.” Substituting one kind of didactic certainty for another, in this context especially, is unhelpful.
posted by Aravis76 at 5:38 AM on January 8 [68 favorites]


This article bothers me.

I don't think anyone doubts that one's life circumstances can contribute to depression, or that antidepressants aren't effective for some people.

But in my case, an antidepressant saved my life. If someone had told me not to take drugs, but instead fix my life first, or chin up because it's society's fault or something, I would have fucking died. I literally would have died. I would have killed myself. I would not have been emotionally or even physically capable of improving my life circumstances without a leg up from venlafaxine.

This isn't to say that antidepressants are for everyone, and it's not to say that we have a good understanding of how they work (we don't), or why they work better for some than others, and it's not even to say that they're not overprescribed. It's just to push back against the absolutist tone of the article. It's true that in some cases, we can observe that the symptoms of depression are caused by traumatic events or unmet needs, but it's invalid to infer from this that all cases of depression can and should be treated without drugs.
posted by a mirror and an encyclopedia at 5:40 AM on January 8 [91 favorites]


Yeah, I have tons of unmet needs. Who is going to fix them, because they're certainly out of my scope of reach, especially because I'm too depressed and anxious to do it myself.
posted by elsietheeel at 5:43 AM on January 8 [49 favorites]


My understanding is that the NHS makes it much easier to get meds than talk therapy, for context. (someone please correct me if I'm wrong)
posted by PMdixon at 5:44 AM on January 8 [2 favorites]


It’s not harder to be referred for talk therapy, but it takes a lot longer to get it because of the appalling resource pressure on the NHS. A lot of GPs will tide over depressed and anxious patients with medication, while waiting for their referral for therapy to actually materialise. That’s an argument for more money for the NHS, not necessarily for less medication; GPs aren’t medicating because they don’t believe in the efficacy of talk therapy, they’re doing it to give their patients something during the ridiculously long wait for therapy. (My friend’s referral took six months to come through, and that’s not atypical).
posted by Aravis76 at 5:48 AM on January 8 [7 favorites]


The mostly typically prescribed antidepressants, SSRIs/SNRIs never did anything for me besides give me unwanted side effects. I went through about a dozen drugs with my psychiatrist before settling on an off-label anxiety med that worked for me.

I doubt I would be alive right now if it weren't for my meds, but, at the same time, I don't think most psychiatrists would've wound up at the same place as my psychiatrist did, prescribing something that was kinda esoteric and uncommon.

I think the problem is probably the over-reliance on SSRIs/SNRIs, rather than medication in of itself, and I think there's too much of a focus on serotonergics, and too much ignorance with regard to other neurotransmitters and meds that may affect them.
posted by and they trembled before her fury at 5:49 AM on January 8 [13 favorites]


GPs aren’t medicating because they don’t believe in the efficacy of talk therapy, they’re doing it to give their patients something during the ridiculously long wait for therapy.

Sure - but there's less of this "meds/other things" dichotomy in the US discourse because it's not the case that meds are universally much easier and quicker to access than basically anything else. Which is not to say that dichotomy's not a thing, just that the concept that the only thing the medical establishment knows to do is put pills in you is one that lines up with more people's experience of seeking treatment in the UK than the US.

(I would say the US behavioral health paradigm has accepted that there are quick fixes that aren't pills and it's called CBT cuz insurance companies)
posted by PMdixon at 5:56 AM on January 8 [8 favorites]


I bought a new car yesterday. It's a new car I can 100% afford, and I love it, and I nearly threw up I was so anxious just to drive it home. I'm feeling similarly about having to drive it to work today. I barely slept last night. I've done therapy for this so I'm able to tell myself that it'll pass in a few days and I'm not going to take anything for it this time, although I should have last night if I'd realized I was going to struggle so much. I have medication for this for a reason.

My anxiety problem has nothing to do with my "not liking my work," sorry. SSRI antidepressants have not been a good fit for me at this particular phase of my life, but this business of treating it like brain chemistry isn't involved because you tried an antidepressant once and it didn't work as well as you'd like is ridiculous. And I'm deeply worried that this guy is referencing things like "an Amish village in Indiana" as his SCIENTIFIC sources for how depression really ought to be treated. This is not how evidence-based medicine works. I'm 100% behind the conclusion that people in the UK need better access to evidence-based treatment involving things other than medication, but this is so dangerous a way to sell that.
posted by Sequence at 6:00 AM on January 8 [22 favorites]


My understanding is that the NHS makes it much easier to get meds than talk therapy, for context.

Some medications. There's at least one antidepressant that's common in the US but isn't prescribed at all in the UK, no matter how many doctors you might ask. Why? Because reasons, apparently.

Ask me how I know.
posted by Mr. Bad Example at 6:09 AM on January 8 [3 favorites]


Somewhat related, and saw on my FB feed today: 30 years after Prozac arrived, we still buy the lie that chemical imbalances cause depression

Though I'm skeptical about that article. It reads like anti-psychiatry stuff (look at how bad medicine has been in the past - leeches, bleeding, humors! See how bad psychiatry is now. They don't know anything!!!), maybe not as anti as Scientology is, but feels like the author has an axe to grind.
posted by k5.user at 6:12 AM on January 8


From the Q&A with the author of the article:

Why do you think it is that doctors hand out so many antidepressants when the wealth of evidence as you present in your book suggests they are largely ineffective?

I wouldn’t want to overstate their ineffectiveness. Between 65 and 80% of people taking antidepressants become depressed again within a year. However, that’s not 100%. Of course some people would have recovered anyway through natural processes. I’m not critical of doctors for this. Part of the problem is that we’ve put the onus for solving these problems on to people who are not in a position to solve them alone. Telling people, as I was told by my doctor, that depression is caused by a problem in your brain is, firstly, untrue and it is also really problematic because it cuts people off from finding the real causes of their depression and anxiety. We’ve been telling ourselves this chemical story for 35 years and every year depression and anxiety gets worse.

posted by mrbeefy at 6:14 AM on January 8 [7 favorites]


It was obvious to basically everyone by the the time I was 13 that I should be on some sort of medication. Is it inborn? Is it environment? Is it unmet needs? Who the fuck knows - but that question kept me miserable and unmedicated until last year, the year I turned 36. I can't believe how much it helps. I wish someone could have gotten through to me earlier that you don't have to answer the question, you just have to see if something - meds, therapy, yoga, whatever - helps. And yes, I started meds because life got much worse and I was way less able to handle it, but things have leveled out somewhat and I'm staying on them because my brain has never been so clear.

I totally get that meds don't help everyone and most aren't so lucky to find the right med right off the bat and that causes more problems that it solves, but articles like this keep people who desperately need to try meds off of them.
posted by I'm Not Even Supposed To Be Here Today! at 6:15 AM on January 8 [15 favorites]


As always, the truth lies somewhere in the middle.

I was talking to someone about how my sense of the world as inherently unsafe is considered a part of my trauma-related mental health issues. But really, in many ways, I don’t feel the world is fundamentally safe or just for anyone, even when I think about it “rationally”. I’m always going to get told I’m not better on my mental health if I have to pass that standard. Similarly with depression- it is hard to enjoy things when you’re poor, when you don’t control your life, when you’re lonely.

But at the same time, plenty of rich people with everything going for them are depressed. Plenty of people who can afford to change their lives are depressed. So it’s clearly not that simple.
posted by corb at 6:16 AM on January 8 [11 favorites]


If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs.

For some of us, those unmet needs used to include selective serotonin reuptake inhibitors.
posted by flabdablet at 6:20 AM on January 8 [52 favorites]


I know the Metafilter consensus is strongly in favor of antidepressants so I'm just going to leave this here before this article is met with a strong wave of derision. This article speaks to my experience. The one time in my life when I took antidepressants was when I was in my neverending graduate program. I had always been fairly happy, maybe a bit anxious once in a while, but nothing close to pathological. But in my (ironically) neuroscience graduate program, I found my self-confidence eroding, the lack of progress was demoralizing and I began to feel trapped - the longer I spent in the program, the more time I had thrown away with little to show for it. I was diagnosed with depression, I was evaluated for ADHD (negative). I spent countless sessions in CBT talk therapy at $10 a pop thanks to the generous university insurance.

It didn't seem to help enough. I decided to get some of these magical antidepressants everyone was talking about. The first thing that shocked me was the cavalier way in which they were prescribed - it seemed more like an art rather than anything precise or scientific - let's try this and then if that doesn't work, let's try that. I started taking Wellbutrin. Within a week I was sitting on the edge of my couch shaking with anxiety, paralyzed by it, unable to do anything. I had all this nervous energy, but the anxiety was overwhelming. I threw up, all over the lab corridors. I decided to quit cold turkey and run away from antidepressants. And I know that Metafilter would say that I should have kept going, trying other antidepressants, until I found a good fit. But actually the solution was simpler: I quit my graduate program, jumped into another career and am now much much much happier. The depression was a clarion call from my body telling me that something was wrong, not something to be medicated away. Just as pain is sometimes a signal that something is terribly wrong and should be attended to (and sometimes meaningless and should be medicated) - so is depression. Please note, I'm not saying that there aren't circumstances where antidepressants aren't the right approach - just as sometimes you need painkillers - but it behooves one to consider why it is that we're feeling the way we feel. Is there something that needs to change?
posted by peacheater at 6:20 AM on January 8 [77 favorites]


"Humans have an innate need to feel that what we are doing, day-to-day, is meaningful."
All that youthful exposure to the Theatre of the Absurd has certainly paid off.
posted by octobersurprise at 6:22 AM on January 8 [5 favorites]


Also, I don't think it's fair to say that the author means that brain chemistry is not involved - obviously brain chemistry is involved. But saying that you have low serotonin levels is only a description - you could fix that and still not understand the root cause of your low serotonin levels.
posted by peacheater at 6:23 AM on January 8 [9 favorites]


Yeah, I'm intrigued—and maybe that's because I'm a creative person and I don't want to fuck around with my brain chemistry too much, because to some degree whatever is going on in my brain works for me, even if it also brings me a lot of pain. I feel like I am mourning a lot of things in my life, and I still have PTSD to some degree from childhood and adult work experiences, and I am frequently very lonely. When I had a dog to cuddle for a while recently, I slept much better at night—I felt connected and close to another being, and I felt like if anyone came into my space, I'd know right away. I had a hell of a time sleeping last night, kept awakening to every single weird sound in the night, and I was just thinking this morning that that's exactly why people get therapy animals, right? The animals get to know you, and they can tell whether you're OK, and if you're not, they remind you that they're there and help you self-regulate. Maybe I need something like that.

I know medications work for many people, and I also know that often the medication that works isn't an antidepressant at all, but rather something to treat another type of imbalance. And sometimes the meds to treat other imbalances can make our mental health worse. And talk therapy can be efficacious in improving our mental health; that points to the validity of the notion that sometimes what ails us is circumstantial, and if we can talk through it and be heard, that can be beneficial. There's certainly no one answer.
posted by limeonaire at 6:26 AM on January 8 [3 favorites]


GPs aren’t medicating because they don’t believe in the efficacy of talk therapy, they’re doing it to give their patients something during the ridiculously long wait for therapy. (My friend’s referral took six months to come through, and that’s not atypical).
Sorry, but that is completely atypical, at least compared to local services here in the West Midlands. Six months? What kind of unrealistic express service is this? It was over two years the last time I was referred for anything. And after two years? Evaluation appointment. Then more waiting lists.
posted by Dysk at 6:29 AM on January 8 [3 favorites]


I dunno. One of the major symptoms of depression is that it interferes with your ability to enjoy things. I'm sure that depression is correlated with not enjoying your job, but it doesn't follow that depression is caused by disliking your job.

I guess that I'm not convinced that anyone has a great handle on how mental health works, and I'm a little skeptical of anyone who pretends that they do. In a perfect world, we'd all be free to experiment with a variety of approaches until we figured out what worked, but of course very few of us live in that perfect world.
posted by ArbitraryAndCapricious at 6:30 AM on January 8 [7 favorites]


a mirror and an encyclopedia - that is exactly my experience as well. I was absolutely on track to end it all and I decided that I at least owed it to my family to discuss my feelings with my doctor. He put me on an anti-depressant.

Within a couple of weeks I decided not to go through with it.

Within a couple of months I was actually feeling pretty good.

I'm not on them now, but I now know that if that black feeling starts rising again, that I have an option that has worked for me in the past and might work in the future.
posted by ged at 6:31 AM on January 8 [12 favorites]


I tried to treat mild anxiety with Guanfacine, and ended up suffering through a five day long panic seizure so severe I was sure I was going to die within days. A brief prescription for Ativan helped me sleep in the short term, but after ten months of gradual improvement I am still a shell of my former self.

However, I am still convinced that for some people these drugs can save lives, even as for others they can, and have, ruined lives.

I believe that, a hundred years from now, many of these same drugs will still be in use, but there will be instantaneous blood chemistry/genetic testing that will predict which, if any, will be effective and which will cause terrible side effects. Given the high incidence of success we're currently seeing with CBT therapy over chemical treatment, there will also be more accurate methods to tell which conditions are primarily psychological, and which are chemical.
posted by CynicalKnight at 6:32 AM on January 8 [5 favorites]


Speaking as someone who has had issues with depression of varying degrees of intensity their entire adult life and who has been on anti-depressants (although it's been at least ten years since I went off them), this does ring true to some extent, although my doctors and therapists never, ever talked about anti-depressants as something that would "cure" my depression. Instead, I was told they were something that would assist me in getting to a level of functionality where I would have the mental capacity to work on the issues that were contributing to my depression, at a time in life when I would have been incapable of addressing larger problems because I was feeling totally overwhelmed by life. The ones I was on also helped me sleep, which was a huge and almost immediate improvement to my quality of life. But yeah, this;

As always, the truth lies somewhere in the middle.

because nobody's depression is the same as anyone else's. I have no doubt that chemical imbalances play a role in the depression that runs through my mother's side of the family (there's no history of depression on my father's side, even though that side of the family was worse off in many ways than my mother's), but I also had a lot of really soul-sucking jobs throughout my 20s and 30s that made getting out of bed in the morning a real struggle. At the age of 44 I've (*knock on wood*) never been happier in my personal and professional lives, but probably also never more anxious and pessimistic about the future and what it holds, so when I get down that's generally what drives it.
posted by The Card Cheat at 6:34 AM on January 8 [15 favorites]


The first thing that shocked me was the cavalier way in which they were prescribed - it seemed more like an art rather than anything precise or scientific - let's try this and then if that doesn't work, let's try that.

This is the exact way my IBS-D was medicated. Weirdly enough, after spending years trying different drugs and attempting to find the exact right amount and type of fiber, it was my brain med that finally balanced it out.
posted by I'm Not Even Supposed To Be Here Today! at 6:35 AM on January 8 [5 favorites]


A thing I think about a lot is that appropriate reactions to unhealthy situations are themselves often unhealthy. I was extremely depressed in middle and high school (and as an adult have been diagnosed with bipolar II) and I think really a lot of what depressed me was the unfairness and misery of living in a sexist and patriarchal society (this might sound eye-rolly but the more I have thought about it the more I think that's what was going on). Reacting with anger and depression to unjust, inescapable situations is normal and understandable and even possibly healthy because it's RIGHT to be mad and it's reasonable to shut down, but it's also personally destructive. I think it'd be great if we could, like, dismantle the patriarchy and maybe if that happened I wouldn't need medicine anymore (but maybe I would!) but for now the medicine helps me function and support myself and my family so I'm going to stick with it. I think, yes, I might well have unmet needs, but it is also often actually impossible for those needs to be met so I will use what I have, even if it's an imperfect solution.
posted by Mrs. Pterodactyl at 6:38 AM on January 8 [67 favorites]


My first week on my drug I thought I was never going to get through it. When it was time to up the dose the adjustment period took honestly a couple months (I was lucky that some of the reasons I'm taking it were resolved immediately which kept me going). If meds are something someone reading this wants to try, unless you can't live through the side effects, it's best to give it at least 60 days. Also, stopping these medications suddenly without doctor's approval can be very dangerous with some of them.
posted by I'm Not Even Supposed To Be Here Today! at 6:38 AM on January 8 [9 favorites]


Screw the ongoing debate about whether the genesis of depression is physical or mental--itself a false distinction since mind-body dualism has always been more about religion and morality than any observable fact--and the accompanying righteous beliefs about treatment. What we call "depression" is probably a huge array of different issues with similar symptoms, some of which are internal and some of which may result from living in intolerable circumstances beyond the sufferer's control. The only common denominator is that this collection of symptoms we call depression ruins lives and kills people, and the right way to treat it is however you can, as quickly as you can. Without regard for the opinion of a journalist and plagiarist with no medical training.
posted by xylothek at 6:41 AM on January 8 [42 favorites]


I am not familiar with this author's work, but I hope that his book is more nuanced than this publicity piece which was annoyingly simplistic. Forget the shills for Big Pharma, we can fix depression by giving everyone a small pony! If they're sophisticated Westerners, get them one of those jobs all the trust fund kids are doing.

My needs aren't being met and I don't feel a sense of control because all my other brain friends mental illnesses have tied my hands behind my back. It's rather fucking difficult to grab the reins of my life from this position.

The real story here is of medical professionals giving out what are essentially bandaids to everybody. The root causes being the dwindling resources being poured into public sector health care and the corrupting influence of the for-profit pharmaceutical industry. Perhaps I've been lucky, but are there any responsible psychiatrists currently practicing who would have found any of this surprising even 5 or 10 years ago? Who don't understand that mental illness has its roots in a complex interaction between biology, personal history, and personal circumstances, that varies significantly from patient to patient?

Here is a more comprehensive overview of the causes of depression by Dr. Robert Sapolsky.
posted by Freelance Demiurge at 6:44 AM on January 8 [10 favorites]


I think the author has correctly identified working conditions as a major contributor to persistent melancholy, but it seems to me he's missed another: FUCKING ADVERTISING.

Most of us spend our waking lives fending off a totally relentless barrage of messaging specifically and explicitly intended to induce a persistent sense of dissatisfaction with what we already have and manufacture needs for things we don't.

This is the exact way my IBS-D was medicated. Weirdly enough, after spending years trying different drugs and attempting to find the exact right amount and type of fiber, it was my brain med that finally balanced it out.

I was once asked by a friend who was right into Iyengar Yoga, in a discussion about the possibility of uploading human minds into the Cloud, why I was "so attached to my colon".

I replied that the connection between mind and gut is profound, mysterious, and does not react well to being ignored.

There's a lot of shared chemistry there.

mind-body dualism has always been more about religion and morality than any observable fact

Word.
posted by flabdablet at 6:45 AM on January 8 [17 favorites]


It's obviously both. I spent a lot of my life with no real hope for the future. Crushing debt, crap pay, chemical dependency, dysfunctional relationships, identity issues, etc.

I've been helped out by various anti-depressants. I've sometimes gone years without looking forward to anything. Often months at a time without doing anything I actually enjoy. Weeks without exercise. Days without proper nutrition.

Sure, turning my job and finances around did more for me than any pill, but I doubt I'd have fixed the other things from my bed.
posted by cjorgensen at 6:47 AM on January 8 [12 favorites]


but it behooves one to consider why it is that we're feeling the way we feel. Is there something that needs to change?

If you ask moderately to severely depressed people, you're likely to hear that the reason they're feeling that way is that they're a terrible person that deserves nothing but pain and that the world is an endless stream of relentless and pointless suffering, and that the thing that needs to change is that they need to stop existing.
posted by GCU Sweet and Full of Grace at 6:47 AM on January 8 [64 favorites]


Thanks for posting this; need more time to read and process but initial reaction is yeah, that's the side of these disorders we under-emphasize but also of course like most things it isn't a simple binary between physical and social/ideal but a complex interrelationship.
posted by saulgoodman at 6:51 AM on January 8 [1 favorite]


we can fix depression by giving everyone a small pony!

If I recall correctly, the jury is still out on therapy dogs, but that means it's possible a small pony might actually help. Or a dog, anyway...
posted by surlyben at 6:56 AM on January 8 [6 favorites]


> If you ask moderately to severely depressed people...

I bet you would also often get a fairly accurate self-diagnosis. When I am in the midsts of depression, I know getting quality food, refraining from alcohol, cleaning the house, getting exercise, doing something creative, doing something I enjoy, will help immensely, but when I lack the motivation to even clip my own fingernails, it's a bit hard to do other self-care tasks.

The smoker knows he needs to quit, the alcoholic often would love to quit, the depressed person would love to do the shit that makes them not depressed.
posted by cjorgensen at 6:57 AM on January 8 [45 favorites]


The things I need to even begin to be not...like I am...would require a time machine. When I'm not medicated I take that train of thought all the way back to "the things needed to make me happy would actually wipe out my existence years before I came along so I was never supposed to be here and maybe I should just go." I prefer my brain exercise stopping at the time machine, even if it doesn't help anything.
posted by I'm Not Even Supposed To Be Here Today! at 7:00 AM on January 8 [7 favorites]


Anyone trying to give a short answer to our how brains work will fail.
There isn't just one neurotransmitter or one pill or one thing that will make things better.

In my case I've had a long and windy roads based on tons of factors, and medication was very appropriate and saved my life. Plus therapy. Lots of therapy .

Recently, I ended up going off all psych medication when I was given medication for my thyroid. That hormone was causing some problems with my sleep and energy levels. I'm still on a pill, but it works so so so much better than the antidepressants ever did.
posted by AlexiaSky at 7:04 AM on January 8 [6 favorites]


I don't see one mention of therapy in this entire article?

I find this author painting a world where people just go straight to the doctor and gulp down pills without doing any personal work. I this happens, but I find this article doesn't even acknowledge it as an option.
posted by teamKRL at 7:05 AM on January 8 [1 favorite]


The smoker knows he needs to quit, the alcoholic often would love to quit, the depressed person would love to do the shit that makes them not depressed.

Yep. I need stability, a stable job that pays reasonably and doesn't destroy me, some modicum of understanding and basic human respect from the people around me, and the threat of impending brexit taking any and all remaining rights and entitlements from me to disappear. Ain't anybody writing prescriptions for any of this though, and it's not like I can just go out and pick any of this shit up. I know what I need, I also know that I can't simply make it happen.
posted by Dysk at 7:05 AM on January 8 [11 favorites]


I got extremely angry at work the other day because I when I was taking some anti-depressants, (I make no secret of this, it's not something to be ashamed about), a person started offering me all sorts of unsolicited advice about getting how to get off anti-depressants and switch over to a vegan probiotic diet because it's so much better for you than medication. This article is giving me shades of that.
posted by Ferreous at 7:06 AM on January 8 [28 favorites]


Speaking as someone who has had issues with depression of varying degrees of intensity their entire adult life and who has been on anti-depressants (although it's been at least ten years since I went off them), this does ring true to some extent, although my doctors and therapists never, ever talked about anti-depressants as something that would "cure" my depression. Instead, I was told they were something that would assist me in getting to a level of functionality where I would have the mental capacity to work on the issues that were contributing to my depression, at a time in life when I would have been incapable of addressing larger problems because I was feeling totally overwhelmed by life.

This is almost precisely what I came to this thread ready to post.

One of the biggest obstacles in battling depression, in my experience, is going into a doctor's visit with both you and the doctor understanding the above -- that SSRIs do not cure depression. They attempt to mitigate the symptoms of depression to make you more capable (whether physically, mentally, emotionally or all of the above) of addressing its underlying causes. You can do that on your own, with therapists, with family and friends, whatever works, but if you OR your doctor thinks that SSRIs are Magic Happy Pills you're in for a hard road ahead.

I fought hard against my own symptoms for well over a decade before I decided that maybe medication could help. My second visit was with a trusted GP who talked it out with me, discussed the potential benefits and side effects of the medicine, described how it had affected other patients of his, and recommended at least a trial basis of psychotherapy to help the process. Everything I could ask for in a doctor. But my _first_ visit was with another GP in his office who listened to my woes, said "Okay, you sound depressed. Here's a prescription for Effexor" and if I hadn't done my homework before going in, I might have ended up in a much worse state. (1) (2)

(1) This is not to slam Effexor in and of itself or to start an Anti-Depressant X Is Great But Anti-Depressant Y Is Satan's Little Helper derail. It is to say that Effexor is one of the anti-depressants that is prone to side effects even when used properly, and ESPECIALLY if misused or taken irregularly or discontinued abruptly, and as such is one of those kinds of drugs that you should know exactly why you're taking it before you start taking it. I came into that visit wary of it and Paxil for exactly that reason and went for a second opinion before diving in.

(2) And why would that have been a potential problem? Surely I, the informed consumer, would not have misused Effexor or a similar SSRI. Well, who's worse at taking pills regularly and following dosage and timing instructions than someone who's severely depressed? And that is a class of medicine in which following those orders is Very Important. I firmly believe that that's part of the stigma behind these meds: J. Random Teen is depressed, and they get handed a pill bottle. They skip or forget doses, the underlying issues are still there, they don't feel any better. They say 'well, this doesn't work' and quit cold turkey and get brain zaps and horrible discontinuation syndrome. They go back to the doctor who hands them a different pill bottle and the circus repeats. No wonder there's a black suicidal thoughts warning label on the bottle when that kind of cycle happens...
posted by delfin at 7:13 AM on January 8 [11 favorites]


"I am not familiar with this author's work, ..."

Johann Hari previously
posted by devious truculent and unreliable at 7:17 AM on January 8 [10 favorites]


I was just reading this article!
It interests me because I have just started taking medication against anxiety, after CBT hasn't helped much, and everything just spiraled downward rapidly. My doctor is skeptical of medicine for depression/anxiety and so am I, but I was in a state where he said he didn't imagine any form of therapy could help before I had gotten some respite from the almost constant anxiety I was experiencing. And the drug helps, I am slowly feeling better. I have a small glimpse of hope.
The thing is, the reason I am not well is my former job situation. I have a new, lovely job but what happened at my former workplace has led to trauma I can't heal, even with help from a great therapist, even in a great new situation. In that sense, I agree with the author. This wasn't my brain suddenly playing a trick on me, it was my brain being damaged by very extreme external forces, and a lot of free time traveling the world with a pony might help, or maybe not because a lot of the problem is that I don't trust other people or even myself anymore.
The thing is, how I read the article and the accompanying interview, he acknowledges that drugs might work for some, and that his situation was/is privileged. So I don't really get the anger here.
I think I may buy the book because I think it may contain some ideas for how to get ahead, with my pills, and my new therapist. And I have a big dog, too.
posted by mumimor at 7:19 AM on January 8 [8 favorites]


Oh yeah, starting people off with effexor is a nightmare. I had a doctor prescribe effexor as his first solution because he didn't want to give me the drug that I found worked well in the past because he claimed the "side effect profile was too severe." Flash forward to two days later and my wife is asking me if I have a concussion.

I'm assuming he's one of the shit ones who got lots of free swag/trips from pfizer.
posted by Ferreous at 7:19 AM on January 8 [3 favorites]


t mumimor: part of the reason people are defensive is because if you are on medication for anxiety/depression/etc, there's always a myriad people telling you how to get off of it, or how you just need to have a positive life attitude or spend more time in the sun. For a lot of us, medication is a lifesaver, in a very literal sense. Obviously it isn't the end all cure all and there's a lot more trial and error in this sort of thing than other fields of pharmacology, but you don't hear people urging people with high cholesterol to get off statins.

Lots of people delay trying medication that could help them for years because of this sort of thing.

This article reads like seeing a person with hemophilia bleeding out and saying "well you just need to make your blood clot" instead of doing what you can in the moment and dealing with the wound.
posted by Ferreous at 7:24 AM on January 8 [27 favorites]


Maybe my more positive impression is from the interview
excerpt:

Has what you’ve learned by writing this book helped to alleviate your depression? Are you, for want of a better phrase, a happier person?
Massively, but I want to just caveat that. What this book is not is a simplistic guide saying: “Hey, I did these things, and now you can do them too.” I think that would be quite cruel because I was in this incredibly privileged position. I had money from my previous book, which meant that I could change my life in quite radical ways in order to strip out some of the causes of my depression. Lots of people are not in a position to do that.


I know some people who are chronically depressed, and it is such a horrible state, one that makes their loved ones feel helpless and sad. I can see why people would try to help, though I've read enough to understand why it is a wrong and hurtful approach. However I can also recognize myself in the story of the rice farmer who got a cow. I do have a sense that what I need to do to recover is to change some fundamental things in my life, without being able to pinpoint which things they are.
posted by mumimor at 7:39 AM on January 8 [2 favorites]


Sure, fine, let's ask for more transparency and rigor in how well-documented claims are of a particular drug's efficacy.

But doubting the premise that ingesting a particular chemical could make a significant difference in how well someone's brain functions? Has this person never heard of alcohol? Amphetamine? Insulin? Glucose? Caffeine?
posted by straight at 7:43 AM on January 8 [1 favorite]


I’m sure that some of the article’s observations have merit, but to offer a counterexample:

A lot of my despair comes from the the physical effeccts of depression. I have a loving family, a house, friends, I live in a city I don’t hate, and I used to have a good job and a healthy lifestyle. I had been diagnosed as depressed as a teenager when my life had a fuckton of problems, but I’d been able to build a new life that I felt pretty satisfied with. I was on a small dose of antidepressants, but I have no idea if they worked.

Then I stopped sleeping, couldn’t focus, had no energy, would swing between anger and apathy, had panic attacks, and lost interest in doing much of anything. I went through a barrage of medical tests, made some lifestyle adjustments, found a great therapist - none of that ultimately helped.

After almost a decade of struggling, I couldn’t make it through the workday physically or emotionally. I was able to retire with a small pension, but because of the depression, I found myself in the situational despair described the article. My career is gone, my financial situation is more precarious, I hardly see my friends, I don’t have the energy to exercise, I don’t particularly want to do anything most days. The worthless and hopelessness I feel came after the physical symptoms of depression ruined the life I had been so satisfied with.

I know that antidepressants are overprescribed and used as an easy panacea instead of identifying the actual causes of emotional distress. But when the author talks about being “drugged” or about how depression comes from external circumstances, I get nervous. I often worry that I’m using the supposed chemical imbalance in my brain as a crutch. I spend a lot of days in bed, not contributing to anything. Of course I’m unhappy, look at what I’ve thrown away because of my laziness.. And sometimes I try to go off my meds to see if I can just.fucking.function like a normal adult, and things get really bad again. It helps to have my doctors and therapist tell me that it’s not me, it's my stupid brain making me sick.

So anecdote not data and all that, but my experience does not align with the cause/effect claims in article. My needs were met, and then depression took them away. I can say for sure that medicine will save my life, but it's making it a lot more tolerable right now.
posted by bibliowench at 8:04 AM on January 8 [20 favorites]


Related: The Americanization of Mental Illness

For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.
posted by ellieBOA at 8:15 AM on January 8 [14 favorites]


I'm Not Even Supposed To Be Here Today!

It may not be so weird as all that when a psych med helps IBS.

The Second Brain is about how much the nervous system does to regulate digestion-- it's a lot, and a problem might be there rather than in an organ.
posted by Nancy Lebovitz at 8:27 AM on January 8 [1 favorite]


but it behooves one to consider why it is that we're feeling the way we feel. Is there something that needs to change?

For a lot of people with clinically diagnosed anxiety disorders, this is absolutely true, and also entirely irrelevant. If the thing that needs to change is “going back and having a different sort of childhood”, then that is a change that would be helpful, but it is not a change that is possible.

For people with PTSD, the solution might be “go back in time and do not become a soldier” or “go back in time and do not be sexually assaulted”.

Changing these circumstances would be great. However, since it is not possible, we find ways to cope now, and sometimes those ways of coping involve medication. Maybe the meds won't be needed long-term, but maybe they will. And that needs to be okay, which is why I'm leery of any hot takes that tend toward the "everyone should be healing until they don't need the meds" viewpoint. My hands don’t go cold and my mind freeze when I hear yelling because of my materialistic lifestyle or competitive mommybloggers, but because of formative experiences when I was small.

I absolutely found that my anxiety peaked when I was in graduate school— in fact, my psychiatrist told me that there was something fundamentally broken about the graduate school environment, because so many of his clients were grad students coming to him in crisis. And that experience was part of why I left academia, so sure, I agree that taking stock of your life circumstances and changing them when possible is wise and that more people should be urged to do that on a regular basis, and that more doctors need to do a better job of distinguishing between situational depression/anxiety and the clinical variety.

However, to assume that "make your life better and you will feel better" is possible for everyone on meds is absurd, and I think pieces like this do a disservice to people trying to cope with the aftermath of adverse childhood experiences (ACE is the search term, if you want to read medical journals on the subject) or trauma. Sometimes you can’t quit or move or divorce the problems, because they are in you, and you still have to find a way to keep going.
posted by a fiendish thingy at 8:28 AM on January 8 [40 favorites]


I understand the impulse to push back against medication as an end-all, simplistic solution, and every agrees that getting out of toxic situations and toxic relationships is essential. If there are people with well-balanced brain chemistry popping anti-depressants to help them cope with some sort of oppressive personal hellscape then "please exit this nightmare ASAP" is good advice. But if we are swapping stories, here's mine:

About the time my daughter turned 10, she started crying for no reason we could see. She'd just begin a crying jag and continue weeping for two or three hours at a time. She was previously a straight-A student; now she was bringing home a slate of Cs with an occasional B thrown in. Teachers reported that she was listless and moody, especially in the mornings. She has good family support, plenty of friends, eats healthy food and plays soccer. She couldn't tell us any reason that she felt bad, she just did. Constantly. We got a referral to a counselor and started weekly sessions. There was some slight improvement, but not nearly enough. Still constantly crying, still anxious, still faltering in school. It was enormously frustrating because neither we nor she could identify any reason for any of it. It just began one day, and it wouldn't go away.

After a year of that we got in to see a pediatric psychiatrist who evaluated her for depression. To no one's surprise, her score was off the chart. Well, that's not true. She was incredibly surprised. AJ had no idea that everyone didn't feel the way she did. She thought the whole world just walked around feeling hopeless.

We came home with a prescription for 10mg of Prozac. We were just beginning a new school year (sixth grade! middle school!) and I was eager to find some solution that would work for her. And the Prozac did it. No more crying jags. Lots of energy. Her grades aren't fully recovered, but on the last report card it was all Bs--much improved. And she is doing things this year she would have never done last year. She went to her first afterschool dance and never left the dance floor. Came home exuberant. She won her class spelling bee and acquitted herself well at the next level. She organized an secret Santa program among her cadre of friends at school. She's completely rocking sixth grade--a really hard year for most people--and there's no way that it isn't all thanks to her daily pill. We're still doing counseling (every two weeks now), but there's not nearly as much to talk about.

YMMV, etc. etc., but in our little family Prozac was a godsend. And part of why I am posting all this is that we should have sought out medication earlier, but there's enormous pressure to exhaust all other possible avenues first, especially for kids. So we put the psychiatrist off until last, but I am 100% convinced that AJ got a bad roll of the genetic dice when it comes to brain chemistry, and nothing was going to fix that but a pill. The difference is remarkable.
posted by Pater Aletheias at 8:34 AM on January 8 [45 favorites]


Drugs can help regain a footing no doubt. And sometimes a footing is needed. But there is much evidence that they don't address root causes.
I would recommend the following book list and especially these first 2 if you have a rational mind and want books with plenty of references to scholarly things.
Gabor Mate- When the body says no
Bessel van der Kolk - The body keeps the score
and also
Alexander Lowen - JOY, in the bioenergetics tradition, which more often labels depression as result of inability to express anger. This has some nice anger exercises that involve full body motions. Get weird and uncomfortable for sure. It has a chapter called "Anger: the Healing emotion" haha!

Language of emotions-Karla Mcclaren
I have also enjoyed this one as a recovering hyper rationalist. ;)

and on the parenting side of things
Listen Wipfler and Schore.

Most of these references make the point that drugs and talking are only portions of the solution and full body engagement(tantrums or screams or sobbing or ...) are important pieces of the puzzle of becoming a thriving human. Not that I am claiming to be there yet but I am enjoying many of the exercises and thought channels these books and friends have been leading me on...
posted by danjo at 8:39 AM on January 8 [3 favorites]


As a life-long sufferer of major depressive disorder (and, now, with added anxiety disorder!), I feel like I can speak to both sides of this argument. In my experience, medication has, in some ways, helped me cope better with the depression. Medication can help take the edge off the overwhelming blackness of the constant depression. It helps me move through life a little better. But meds don't come close to making me a good little worker again. Not by a long shot. That said, I do believe that there is some level of a physiological component to some types of depression.

There are definitely serious aspects of our world, outside our control, that do not contribute to a healthy mindset. In fact, a lot of it seems directly targeted against a healthy mindset. The messaging we receive that we must be tireless workers, that our monetary status is the only legitimate measure of our personal worth as people, that we should be happy buying shiny new things, etc. etc. It grinds you down. Doubly-so, if you're already disposed to depression already.

This part doesn't get much play in media (or society as a whole) because it speaks directly in opposition to the underpinnings of how our society is structured and operates. Call it capitalism, if you will. But, to suggest that our world system is driving people into deep depression is to court blasphemy and/or treason. It shall not be heard.

So, people like myself are kind of stuck. We have deep, serious problems. But, the solutions are the usual meds and talk therapy. Lather, rinse, repeat. Lately, I've noted that the therapy component (here in the US) is becoming more and more a tool available only to those with deeper pockets than mine, as insurers require large co-pays for each visit (which tends to discourage weekly visits, even though they may be desperately needed. On top of that, it's becoming harder to find therapists or counselors that take insurance at all. Some advertise a sliding scale, but I've found such arrangements to be pretty limited in their ability to make regular visits financially practical.
posted by Thorzdad at 8:40 AM on January 8 [15 favorites]


Drugs can help regain a footing no doubt. And sometimes a footing is needed. But there is much evidence that they don't address root causes.

and

full body engagement(tantrums or screams or sobbing or ...) are important pieces of the puzzle of becoming a thriving human

A couple of weeks ago I screamed aloud, just effing shrieked, because a bag of popcorn broke in the parking lot of the Target and then sobbed like a maniac at a Raffi song but TBH I'm pretty sure it just means I needed to adjust my medication.
posted by Mrs. Pterodactyl at 8:43 AM on January 8 [12 favorites]


I'm going to my GP today to talk about antidepressants at my therapist's insistence because last week, for the first time in the 7 years I've been in CBT, the pain of the emotions I'm trying to deal with was strong enough that I tried to turn it into physical pain rather than keep dealing with it emotionally.

I do not think I have long-term brain chemistry issues. I think the weight of things that are happening now are drowning out my ability to cope, and I think my therapist believes we can find a short-term solution to bolster my defenses while we continue to work on the underlying foundations.

I also know that I'm *lucky* - I have a good, thoughtful therapist, insurance to cover my needs, and a community of people around me across the spectrum to learn from.
posted by hanov3r at 8:44 AM on January 8 [1 favorite]


Yea, all this stuff about work environments and stuff causing depression drives me nuts. I was suicidal before I was legally old enough to work.
posted by the agents of KAOS at 8:48 AM on January 8 [16 favorites]


It's frustrating how often "is everything you know about [medical condition] wrong" articles present a binary choice between short-sighted assembly-line over-medication, and woo. If I'm using the wrong wrench, it is equally dumb to keeping whacking away harder with the same wrench as it is to give up on wrenches entirely.

A depressed and anxious person can be a machine with malfunctioning parts and also a human being with unmet needs.
posted by allegedly at 8:57 AM on January 8 [30 favorites]


Drugs can help regain a footing no doubt. And sometimes a footing is needed. But there is much evidence that they don't address root causes.

I was initially very skeptical when my nephew, who physically and personality-wise resembles me a great deal, was assigned a Ritalin-a-like at age 11 or so. But, in addition to ADHD, he was also increasingly exhibiting anti-social behaviours as well. Similar behaviours I have to admit to also having as a kid and that took until mid twenties to train myself out of.

But my nephew immediately gained some peace on the drug treatment. That allowed him to be stable enough to go to therapy to deal with his developing behaviour issues. Now, as a late teen, he's at a place emotionally, developmentally, I didn't get to until nearly a decade later. Drugs created that place to start for him, and gave him the breathing space for talking therapy to start to work. Therapy which, before the drugs, had been useless.

I think everyone has to find their own treatment. What works for you may not work for others and vice versa. Pharmacology has to be be an option, but only option, for everyone who might need it.
posted by bonehead at 8:59 AM on January 8 [4 favorites]


BTW, the drug that is helping me get better is Effexor, and the only "side effect" I'm experiencing is that my IBS has almost disappeared. My doctor was surprised by that, so I'm glad to see others find a similar gut-brain connection.
So just from my anecdotal reading and experience what is really bad for some is good for others and there are still un-researched aspects of this. At least here, psychiatry is understaffed and under-funded, so it isn't hard to imagine that there is still a lot to discover.
One thing I've looked at is garden therapy: 'Without this, I would have killed myself': gardening helps heal refugees' trauma, I've even visited a facility, which is unfortunately only available for vets right now. They are a strictly evidence-based facility, and work with psychiatrists and medicine as well as the therapy.
posted by mumimor at 9:01 AM on January 8 [2 favorites]


you don't hear people urging people with high cholesterol to get off statins

If you spend any time around the Paleo / keto / Whole30 world, you definitely hear those things. Not to derail from the main point of the thread about antidepressant drugs, but there's a lot of newer research and skepticism about "high" cholesterol and the usefulness (or not) of controlling it with statin drugs.
posted by theorique at 9:14 AM on January 8 [9 favorites]


My own experience falls more on the environmental side of this, but every depression is different, so whatever works for you is whatever works for you. Depression started for me when I was a kid, and if you had seen me then, you probably would have chalked it 100% up to brain chemistry because there was seemingly no good reason for it. It wasn't until I was an adult and far away from my parents and the place I'd grown up, after over a year of therapy (and after seeing 3 different therapists which weren't a good fit), that I was finally able to articulate what had been bothering me all those years (which didn't magically fix everything either, though it helped a lot). I was lucky that even at its worst I was able to sort of pull myself together and drag myself through daily life, so no meds worked out for me. But who knows, maybe my brain is physically more susceptible to depression than average. Like with most things, there isn't a single story.
posted by airmail at 9:17 AM on January 8 [3 favorites]


So okay, I've fought with depression and anxiety my whole life, too. I've also been watching my mental health deteriorate slowly since 2013, in part because I've been hit with at least one major external stressor every six months since July 2013. I started listing them here, but honestly, I started shaking a bit; they've included apartment destruction, four moves, literal and figurative abandonment, negotiating multiple complex bureaucracies on my own, loss of a beloved young pet, multiple unexpected large financial stresses, and a Whole Bunch of Miscellaneous Family Crap.

When I started wrestling with this, I could laugh off these things without really stumbling; by two years in, I was looking for therapy as a means of being supported and validated that yes, this was a lot of external shit. I did not actually initially have a lot of success; my first therapist tried very hard to push mindfulness on me, which was something of a problem as my primary coping strategy was deliberately blocking out many of the scary things until I could do something about them.

I went on meds two years ago. I think of them as being like braces: ideally, I would not need them because ideally, I would not keep getting hit with external stressors that cumulatively make my mental health fragile and keep me so exhausted. Ideally, I would have the time and support I need to heal and let me work through those microtraumas and not feel threatened on all sides. That's not an option right now or, honestly, possibly ever. I don't have the time: I need to make progress on graduating. I don't have the money: I need to pay off debt. I have support from friends, but they're about as stressed and grappling with traumas as me. In many ways, I have it better than others.

So I lean on my meds and I keep moving forward, because there isn't any way for me to take the level of rest and light work that I'd need to fuel my original levels of resilience. The best I can do is the best I can do, and right now that has to be supported by medication so that I don't spiral into a considerable worse place.

They're braces. They're not fixing the problem. But they're a damn sight better than nothing at all, and until we create a democracy with one hell of a more effective social net, they're the best thing I have access to while I try to heal up enough to take the next hit.
posted by sciatrix at 9:18 AM on January 8 [17 favorites]


BTW, the drug that is helping me get better is Effexor, and the only "side effect" I'm experiencing is that my IBS has almost disappeared. My doctor was surprised by that, so I'm glad to see others find a similar gut-brain connection.
So just from my anecdotal reading and experience what is really bad for some is good for others and there are still un-researched aspects of this. At least here, psychiatry is understaffed and under-funded, so it isn't hard to imagine that there is still a lot to discover.


Good to hear, and very true -- there are still a lot of question marks about how and why these drugs do and don't work. The brain is an extremely complicated instrument and depression and anxiety rarely have discrete and objective symptoms.

There are (or at least were) two versions of Effexor -- the 'plain' immediate-release variety and the XR extended-release variety. The former was much more notorious for side effects because even on strict dosage timing your brain chemical levels could rollercoaster. The latter helps it keep a more even bloodstream distribution.
posted by delfin at 9:23 AM on January 8 [1 favorite]


I agree with those noting that debating whether depression is caused by a chemical imbalance in an individual's brain or by exposure to damaging life circumstances is simply silly. It's like having a debate over whether wrist pain is caused by internal biological factors or by getting injured. Obviously either or both can be the cause for a given person.

Telling people not to take pain meds for their wrist, but rather change jobs to one that doesn't involve repetitive wrist motion, because pain meds won't solve the problem, would be cruel. It would leave them in pain. Some would eventually cure this pain because it was indeed caused by their work conditions, and they are able to make a major career change for the better. But this option is mostly open to the privileged--if you are poor and/or facing discrimination, being told "your pain will go away once you get a job where you don't have to do manual labor or type" is essentially leaving people in pain and then victim-blaming them for it. Meanwhile, the insistence that all wrist pain is externally produced ignores the fact that wrist pain can arise from all sorts of internal causes--you won't cure an infection or leukemia by changing jobs, and in fact could die following such a treatment plan. And even wrist pain that is clearly related to an external cause, like repetitive motion involved in a food preparation job, is likely related to internal factors as well. Give two people the same job, and one may develop a repetitive stress injury while the other does not.

So: it's silly to have a nature/nurture debate about why we experience pain--whether physical or emotional. It's obvious both internal and external factors play a role. The question then becomes why we keep having this ridiculous debate.

In the sociology of the body course I teach, one of the key things we look at is how Western society has been obsessing over the concept of a split between the body and the soul/mind for a long time. Because the mind or soul is presented as both superior to, and somehow separate from, the body, many people find the assertion that a pain in the mind/soul can be caused by the body offensive. They hear, " Your existential suffering is just a like a gas pain--meaningless." The mind is supposed to control the body, not the other way around, under the ideology of Cartesian dualism. Treating a pain in the soul with a drug is seen as basically heretical.

But we also inherit a tradition of rationalist materialism that has been around since the Enlightenment. This tradition ignores anything smelling like mysticism and views human beings as mechanisms that can be studied empirically. Our mechanical actions can be made more efficient, producing better laborers, athletes and soldiers. Our injuries can be effectively healed to keep us productive, healthy and happy. This ideology comes in a progressive flavor, promising, for example, antidepressants made cheaply available to all, reducing our collective suffering. This is the public health perspective.

But this same mass deployment of medications to reduce depression and anxiety can well be critiqued as oppressive. Go ahead, 1%--produce greater income inequality and make working conditions more deadening! Corporate employees can be drugged into remaining productive. Go ahead, states--allow discrimination without fear of revolution! The oppressed can just take pills.

So we have those who see antidepressants as insulting to a higher human nature, those who see them as a panacea, and those who see them as a tool of oppression. Add to this our society's long shaming of mental illness as the product of a bad soul--something to be cured by wrestling with one's demons and becoming a better , more worthy person. Facing that ideology, many find the realization that their symptoms can be treated with a pill an incredible release from shame and self-blame. For them, being told that they shouldn't need to take pills is itself traumatic and a source of anxiety and depression.

Put two people in a room, both of whom have suffered from depression. One of them can be in a camp of people who have a panic attack when they are told they shouldn't need medication for panic attacks, fearing the medications that have allowed them to survive will be taken from them. The other can be a victim of child sexual abuse, a violent hate crime, a war refugee, etc., who wants to mobilize people to stop war, fight bigotry, or end heteropatriarchy, but has simply been given a prescription for meds by some doctor who listened to them for 10 minutes and told them they have a serotonin problem. It's hardly surprising if those two people wind up traumatizing one another.

I think it's important to understand the various ideologies that underlie the debate over how to treat mental illness, so we can see why it won't just settle down. It's kind of a debate over human nature and the nature of our own suffering.

For me, the idea that the mind and body can be separated is as silly as the debate over whether we are creatures of nature or nuture. We are always inevitably both mind and body, both a product of our biology and our societies. What really matters when it comes to mental health is that we reduce suffering, and our suffering has both intrinsic and extrinsic causes. We should use medications to reduce our pain and anxiety, and we should also address the life circumstances that produce pain and anxiety.

What exacerbates our suffering as individuals is when we know that our pain can be addressed with medication, and we are told not to take it, or when we know our pain is caused by cruel life circumstances, and we are told to just take a pill. We need to give people access to antidepressants and antianxiety medications, AND fight social injustice. The either/or debate is counterproductive and actively causing people more pain.

The problem is, as I've noted, that the debate won't just go away, because it is a proxy for a debate between deep ideological commitments. So I think we need to air those out.
posted by DrMew at 9:31 AM on January 8 [51 favorites]


From the article: She told me that when “you have a person with extreme human distress, [we need to] stop treating the symptoms. The symptoms are a messenger of a deeper problem. Let’s get to the deeper problem.”

Er.

When you have a broken leg, the pain is a symptom. It may even be the symptom that convinced you to see a doctor instead of just "walking it off." You set the bone and put on a cast - that addresses the deeper problem - but you don't pretend the pain is irrelevant because it's "just a symptom." It, too, can prevent you from functioning, and you can't heal anything else if you're overwhelmed with pain.

He knew the published scientific evidence, and it was clear: it showed that 70% of people who took them got significantly better.

Did it show that people with the same symptoms who never took those medications were better off than the ones who took them and stopped? Because "you should stop taking these meds when they have helped you make the adjustments you need" is very different from "you should never take these meds."
posted by ErisLordFreedom at 9:33 AM on January 8 [6 favorites]


...I have tons of unmet needs. Who is going to fix them, because they're certainly out of my scope of reach, especially because I'm too depressed and anxious to do it myself.

You can't get your shit together unless you have your shit together.
posted by StickyCarpet at 9:41 AM on January 8 [9 favorites]


I suspect a good portion of therapy sessions these days are about anxiety about the madman in the office.

My chief unmet need is for a President who isn't an incompetent, racist, rapist asshole who spends all of his time tweeting about what he sees on the TV. Can I get a prescription for a new government?
posted by fifteen schnitzengruben is my limit at 9:45 AM on January 8 [5 favorites]


I can't find the article now, but I read a really good description of why mood meds can help IBS. Regardless, there are several that have been studied for that use. I take cymbalta. The adjustment periods were hellish, and not realizing I could be off Linzess made it worse for a while, but now it's amazing. Lots of body aches fixed, mood stuff leveled, I never lost "me" in all of it - it's actually like I'm a better me than I've been in years. The "I literally can't stop sobbing if I start" and "oh I guess I really can't drink like I did before" lingering side effects are entirely worth it.
posted by I'm Not Even Supposed To Be Here Today! at 9:46 AM on January 8 [2 favorites]


I can't remember where I read about this, it posed as scientific, and may have been. In fact I will look for it. Anyway people were getting fecal transplants for gut problems, and suddenly becoming depressed. They checked back with the donors and there was a correlation between the gut biome and passing on depression. So, they started collectiong fecal material for transplant from happy, skinny people. Actually the article titles are so fecal/facile, I will leave it up to you mefites to search. Best to everyone.
posted by Oyéah at 9:48 AM on January 8 [5 favorites]


you don't hear people urging people with high cholesterol to get off statins
Really, as someone with hypertension (an actual condition I suffer from and can speak to from experience, unlike the subject of this post) shouldn't I maybe eat better and get more exercise rather than taking pills? The fact that I don't bother to do that doesn't make me mad at other people who point out a better way, I'm just mad at myself for not implementing it.
posted by Octaviuz at 9:55 AM on January 8 [1 favorite]


There are those who do all the diet and exercise stuff and still have hypertension. Maybe they're mad that people keep picking at their food choices instead of understanding that the pill is their only real option. Some type II diabetics will never respond solely to a low carb diet and weight loss, some type II diabetics could respond to that with great effort but they don't find any reason to avoid metformin because it helps all sorts of things and makes living a little less treacherous.

I am glad some people are able to change their lives or outlooks or diets or whatever and get not depressed, but for some of us no manner of sun lamps, kale, running, meditation, quitting our jobs, etc will actually make it so the meds aren't needed, aren't helpful, aren't saving us. We're not mad or frustrated because we just don't have the willpower to lift weights and drink an extra two glasses of water a day, we're frustrated because people keep insisting that's what we need.
posted by I'm Not Even Supposed To Be Here Today! at 10:06 AM on January 8 [19 favorites]


Agreeing with others that the either/or binary presented here is unhelpful, even if there is definitely merit to the author pushing back. In fact, the author proposes a perfectly reasonable framework (and presumably the book goes into this more):

"I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise – alongside two real biological factors (such as your genes) that can combine with these forces to make it worse."

The seven-two ratio intuitively seems like a fair way to look at things. At the same time, I became more suspicious of the argument at this passage:

"I wanted to tell him: “This pain you are feeling is not a pathology. It’s not crazy. It is a signal that your natural psychological needs are not being met. It is a form of grief – for yourself, and for the culture you live in going so wrong. I know how much it hurts. I know how deeply it cuts you. But you need to listen to this signal."

No doubt this could totally be the correct thing for current-Johann to tell past-Johann. But so much about the lived experience of mental illness is precisely not being able to trust this signal! The source of the signal may indeed be life circumstances, or even just basic body awareness, but it gets amplified beyond reason or muffled, or modulated wildly in all directions. So much of my own struggle with anxiety and depression has been a process of learning to be aware and accepting of these intense signals, understand developmentally why I respond in this way (hi childhood trauma), and learn better ways to address situational/life/habit challenges without overreacting to the signal information. But it's also been a process of learning how to bring the signal back to a reasonable threshold via a mixture of antidepresssants, hormone therapy, regular body habits/avoiding depressants and stimulants, walking a lot, and other things that concretely target the signal itself (as it manifests in my body and brain). Without this second step, which currently requires a little medication, my system would be overloaded and continuously thrust back into fight-or-flight mode, which was burning my entire body out in a profoundly dangerous way.

I'm curioust to read the book now, because I could see it tackling some of these aspects of signal-modulation or not. I'm certainly amenable to the idea of needing new metaphors and distrusting the biomedical narratives, absolutely, but I hope it engages with this lived reality as well.
posted by elephantsvanish at 10:08 AM on January 8 [3 favorites]


When I am in the midsts of depression, I know getting quality food, refraining from alcohol, cleaning the house, getting exercise, doing something creative, doing something I enjoy, will help immensely, but when I lack the motivation to even clip my own fingernails, it's a bit hard to do other self-care tasks.

The thing is, these are all self care tasks that only need to be done by ourselves because of life circumstances.

For about a year or two of my life, I had a combination of great circumstances- four sources of income and a boss that let me manage myself - that let me essentially pay to have these things done for me. My laundry went out in a bag and came back nicely folded. Tasty, healthy food was delivered to my door when I needed it. I paid for a housekeeper. I could afford to take awesome vacations and do things whenever they appealed without having to worry “could I afford the rent”. I made my own work hours and worked from home when I felt like it.

Perhaps unsurprisingly, while my depression didn’t actually Go Away, the symptoms went way, way down once I didn’t have to spend time fighting all of the shitty life circumstances. 9-5 jobs are fucking stressful. Not being able to be late is fucking stressful. Doing the full time job of managing a house while also doing the full time job of being a parent and working in the way jobs are set up is fucking stressful.

Yes, we can’t necessarily change society to fix our depression, but I do think it’s worth noting that a lot of the problems are class or economic problems that could be mitigated if the world were better. It might also make people feel less that Something Is Wrong With Them.
posted by corb at 10:15 AM on January 8 [16 favorites]


"Depression" always makes me think of "pox". The right cure for your pox depends on exactly what sort of pox you have. Chickenpox and smallpox and cowpox all require different treatments. I suspect the same is true of depression, with the difference that we don't understand the different sorts of depression well enough to know which treatment will work for you.

Antidepressants work for some people, and specific antidepressants work for different people.

Getting a job where you're more in control works for some people.

No longer being oppressed by the patriarchy works for some people.

Finding Jesus works for some people.

And placebos are effective for some people, too, as meta-analysis of antidepressant studies have shown.

I don't think we're at a point where we can dismiss any of the cures as useless.
posted by clawsoon at 10:16 AM on January 8 [4 favorites]


The medication argument strikes me like arguing against crutches.

We know that sometimes over-reliance on crutches can hinder healing. We also know that sometimes a crutch is absolutely necessary. We also know that sometimes the person straight-up isn't going to heal (amputation, for example), and they'll need a crutch (or prosthetic) for life.

Expecting medication alone to solve the problem does seem foolish, and there are certainly times where we need to say, "perhaps you should change your lifestyle so that you stop twisting your ankle" instead of prescribing that crutch.

But that lifestyle change doesn't undo the current damage, it doesn't happen instantaneously, and there's no reason to discount medication entirely just because it's not a panacea.
posted by explosion at 10:29 AM on January 8 [3 favorites]


Whenever I read an article like this I think "I live in a world in which most people would want me dead because I love the wrong gender and some of those who would want me dead are very much in political power, and it's just by lucky accident that I don't live in a specific place and time where it's socially acceptable for my death to be actively pursued." How do I change that?
posted by treepour at 10:30 AM on January 8 [17 favorites]


It's just as if a man were wounded with an arrow thickly smeared with poison. His friends & companions, kinsmen & relatives would provide him with a surgeon, and the man would say, 'I won't have this arrow removed until I know whether the man who wounded me was a noble warrior, a priest, a merchant, or a worker.' He would say, 'I won't have this arrow removed until I know the given name & clan name of the man who wounded me... until I know whether he was tall, medium, or short... until I know whether he was dark, ruddy-brown, or golden-colored... until I know his home village, town, or city... until I know whether the bow with which I was wounded was a long bow or a crossbow... until I know whether the bowstring with which I was wounded was fiber, bamboo threads, sinew, hemp, or bark... until I know whether the shaft with which I was wounded was wild or cultivated... until I know whether the feathers of the shaft with which I was wounded were those of a vulture, a stork, a hawk, a peacock, or another bird... until I know whether the shaft with which I was wounded was bound with the sinew of an ox, a water buffalo, a langur, or a monkey.' He would say, 'I won't have this arrow removed until I know whether the shaft with which I was wounded was that of a common arrow, a curved arrow, a barbed, a calf-toothed, or an oleander arrow.' The man would die and those things would still remain unknown to him.
The Parable of the Poisoned Arrow

We can debate root causes of depression until the cows come home, but ultimately seeking out and doing what works for each person dealing with the condition, is going to reduce the pain more than any philosophical debate. "Whatever works" should be our motto. And it will be different from person-to-person.
posted by theorique at 10:39 AM on January 8 [5 favorites]


I DID make a lot of the life changes the author talks about. I quit my awful job and got one I liked better. I make more money now. I made time for my hobbies and my friends. I made myself a work schedule that allows me to get the amount of sleep/rest I need. My work is fulfilling and interesting, and I love the people I work with. I am in therapy to work on all the stuff from my childhood that was contributing to extremely poor coping skills and decision-making. My coping skills are better and I've had a lot of breakthroughs. I don't feel angry at my family. I've set boundaries that have led to better interactions with family.

But I still have depression. The only way that I was able to GET to the better life was because my pills transformed me from a subhuman bed-lump to a semi-functioning adult. Getting a better life did help me feel better, but it didn't eradicate my depression or make it so that I didn't need medication.

I think I also especially bristle at this article because it validates the lies that my own depression tells me: namely, that if I just worked a little harder, that if I were just a little better, I would be totally fine. I have worked hard to overcome that lie and here's this guy telling me that if I just worked harder on changing my life, I would be totally fine. NOPE.
posted by catwoman429 at 10:39 AM on January 8 [30 favorites]


whenever people are like ‘meds are just treating the symptoms, not the root cause’ i want to know whether they say the same thing to people with glasses
posted by beerperson at 10:41 AM on January 8 [26 favorites]


The statistic about 65% of people having depression reoccur within a year struck me as kind of besides the point, at least for myself. I've had depressive episodes while on meds. I've had depressive episodes while off meds. They happen much more frequently off meds and are (subjectively and in memory) worse than those on meds. There were generally external triggers, but once the episode started, I found that I was clawing for metaphorical air even after the trigger had been resolved.

Meds should not be the only solution we turn to. But they should not be thrown out the window. I think a lot of us get very defensive because we see this as being told "You're lazy and stupid. If you had just more will and had thought this through you would have cured your depression with rainbows and puppies." Which, to someone who has gone through that black pit, is a direct attack. I know it wasn't meant this way. And that actually improving the conditions of many people would help deal with many mental illnesses. But that doesn't mean that I'm not terrified of going off meds.
posted by Hactar at 10:46 AM on January 8 [8 favorites]


catwoman429: I have worked hard to overcome that lie and here's this guy telling me that if I just worked harder on changing my life, I would be totally fine.

I didn't get that from the article, though perhaps I glossed over some bits. I got from the article that depression can be helped if people's lives are changed for the better. Prescribing someone a better job and then getting that job for them is a different thing from telling someone that they need to get a better job. Perhaps the author is dreaming of pie-in-the-sky solutions - no more oppression! actively supportive communities! - but I didn't get a "pull yourself up by your bootstraps" vibe from it. I got that sometimes you need to give someone new boots that fit better instead of prescribing painkillers for their crushed toes. That's different from telling them they better go buy new boots that they can't afford.
posted by clawsoon at 10:52 AM on January 8 [10 favorites]


In re the parable of the poisoned arrow, it kinda matters what the poison is. Yes, there's such a thing as worrying more about the history of a problem than how to deal with it, but it's not like they're diametrically opposed.
posted by PMdixon at 11:13 AM on January 8 [2 favorites]


Really, as someone with hypertension (an actual condition I suffer from and can speak to from experience, unlike the subject of this post) shouldn't I maybe eat better and get more exercise rather than taking pills? The fact that I don't bother to do that doesn't make me mad at other people who point out a better way, I'm just mad at myself for not implementing it.

I have primary hypertension with no detected underlying physical cause. I previously had healthy, even low blood pressure. I was already eating a healthy diet consistent with the DASH diet. I was already exercising in healthy and appropriate ways. I was already at my doctor's suggested weight for me. Suddenly, I got hypertension. Regardless of the cause, that puts me at elevated risk of stroke and heart disease. So I take pills.

So yes I do get mad at people who tell me if I did all the things I was already doing, I wouldn't have the hypertension that I have, and I wouldn't have to take pills. And it really makes me sympathize with my friends who were already happy in their lives until suddenly they weren't because they have a mental illness which for some reason society can't accept and insists is their fault.
posted by hydropsyche at 11:24 AM on January 8 [11 favorites]


As I have written before, Johann Hari, is a deeply malicious falsifier. He's the British Jayson Blair or Stephen Glass. He is a very smart person who has often bent his intelligence to unethical and self-serving ends and who has never given a sincere apology for his acts.

There is certainly some truth in this article, because no British press will publish Hari's work any longer without strenuous fact-checking for the fact-checkable bits, but take the overblown spin and opinion bits with a grain of salt.
posted by anotherpanacea at 11:28 AM on January 8 [30 favorites]


One of the useful things I've found is the ability to distinguish situational depression (I am depressed because things in my life objectively suck) from a more (presumably) chemically based depression (Things in my life are objectively pretty awesome, and I am also depressed.)
posted by rmd1023 at 11:42 AM on January 8 [6 favorites]


> flabdablet:
"I think the author has correctly identified working conditions as a major contributor to persistent melancholy, but it seems to me he's missed another: FUCKING ADVERTISING.

Most of us spend our waking lives fending off a totally relentless barrage of messaging specifically and explicitly intended to induce a persistent sense of dissatisfaction with what we already have and manufacture needs for things we don't.

This is the exact way my IBS-D was medicated. Weirdly enough, after spending years trying different drugs and attempting to find the exact right amount and type of fiber, it was my brain med that finally balanced it out.

I was once asked by a friend who was right into Iyengar Yoga, in a discussion about the possibility of uploading human minds into the Cloud, why I was "so attached to my colon".

I replied that the connection between mind and gut is profound, mysterious, and does not react well to being ignored.

There's a lot of shared chemistry there.

mind-body dualism has always been more about religion and morality than any observable fact

Word."


I have been experimenting with some vitamin and prebiotic usage, and have been feeling better than I have for a while.
posted by Samizdata at 11:47 AM on January 8


> surlyben:
"we can fix depression by giving everyone a small pony!

If I recall correctly, the jury is still out on therapy dogs, but that means it's possible a small pony might actually help. Or a dog, anyway..."


Well, my cat quite literally saved my life at one point, so, yeah...
posted by Samizdata at 11:48 AM on January 8 [2 favorites]


anotherpanacea: As I have written before, Johann Hari, is a deeply malicious falsifier. He's the British Jayson Blair or Stephen Glass. He is a very smart person who has often bent his intelligence to unethical and self-serving ends and who has never given a sincere apology for his acts.

Ouch. From the Guardian link:
The fact is that the liberal media likes the sort of "colour" journalism that Hari provides – the telling quote, the saucy detail, the heart-wrenching testimony. The Hari school of falsification is a lucrative form of infotainment. Ideally it wouldn't be completely riddled with fabrications, but that style of writing does lend itself to embellishment, exaggeration and invention.
Now I don't know if that farmer and cow ever existed.
posted by clawsoon at 11:57 AM on January 8


It's so interesting to me how people with the same "basic" problem can have such divergent experiences. A bit like how ADHD can simultaneously be over-diagnosed in some people and under-diagnosed in others, or how some people can be "over"-medicated for chronic pain and others can't get anyone to take their overwhelming suffering seriously.

My experience was that everyone was so invested in me taking medication. And I was the population that is "supposed" to benefit from SSRIs, the severely depressed person where statistically they actually do something. Well, they sure did. My life got worse in every way once I started taking them and improved once I stopped. I had a biological problem, it absolutely wasn't that everyone was refusing to listen and trying to absolve themselves. Now I'm told I'm not allowed to talk about my experience because it might discourage other people from trying medication! It's a deep mystery why I might still be depressed...
posted by threementholsandafuneral at 12:01 PM on January 8 [4 favorites]


Now I'm told I'm not allowed to talk about my experience because it might discourage other people from trying medication!

If someone is telling you that, they're wrong. I don't get that from this thread, tbh. But if you're telling people they should never, ever try medication because it didn't work for you and therefore it's bogus, that is what many people (me included) have an issue with.
posted by cooker girl at 12:06 PM on January 8 [20 favorites]


I was 25 when I was finally asked by my doctor "do you worry more the usual?". And I realized that I had no idea how much worry was usual. I knew I worried more than some people around me. But to put it in econ terms, that was my comparative advantage. I was more prepared. I usually knew the answer because I hadn't just researched for the immediate questions, but all the follow-up questions that might show up.

I didn't really notice the depths of my depression until I noticed my privilege. I had run out of excuses for feeling like everything was terrible and the world was better off without me. I could clearly say that my emotional reaction to my life was out of sync with both societal and my personal expectations of a decent life. If I didn't have a family with financial resources to start me off, and a decent paying job and a relatively secure life, I would certainly be suffering more. But since my suffering was understandable, I'm not sure I would put a priority on my mental health.

Over the last year, a number of legitimate stressors have been popping into my life. Public discussion about sexual misconduct has fractured a lot of relationships, including close family members. My aunt died suddenly. I'm following up on health issues while being fat, which brings up similar questions about whether I've personally put in good enough work to be allowed medical treatment.

It's been interesting to work with my therapist and find that while the anxiety and depression don't go away, having professional help has kept me functioning. Which is to say that while our political climate might be causing a public mental health crisis, remembering that it can be both gives you the energy to help make things better.
posted by politikitty at 12:07 PM on January 8 [3 favorites]


Well, I wouldn't have survived my first bout with schizoaffective disorder triggered by situational depression at all if not for pharmacology, but there was also definitely a point when the meds had outlived their usefulness for me, and once I wasn't actively hallucinating or having active paranoid delusions anymore, it was a relief to be able to ween myself off the meds and get back to having normal human feelings for a few years while my main focus in life was parenting my son and trying to prepare for the future and what once looked like it might still be a planned, secure retirement age. Now all bets are off but I still personally wouldn't turn back to the hard anticonvulsants and antidepressents and ADHD meds unless I was feeling the schizoaffective disorder symptoms again.
posted by saulgoodman at 12:18 PM on January 8 [1 favorite]


I have had major depression since, well, before I can remember. Or depending on how you define it, "bipolar, where the normal is 'feel shitty always' interspersed with 'only borderline instead of full-on suicidal, provided the meds are working', and bee-tee-dubs, there's no manic episodes so you don't even get any sort of high for fleeting moments sry".

Here is my observation:
  1. This illness does not provide me any benefit. I have empathy for others with mental illness, but I chalk that up to my dad more than anything else. In my experience, there are as many shit people with depression as there are shit people without it.
  2. A regular schedule, one that has you socializing, getting activity, eating well, regular periods of productivity, takes you away from negative time-sucks--of course a person is going to feel better. That's no surprise.
  3. Jobs and hobbies you love: see the previous point.
  4. The job of meds is not to fix everything and turn you into a Perfect Person. The job of meds is to stabilize you enough to help you reach the point where you can get to (2) and (3).
  5. Depressed People, Category I: they have the internal and external support systems that allow them to recover from their shit periods. They can either build up or take advantage of the resources necessary to establish (2) and (3).
  6. Depressed People, Category II: For whatever reason, things are so bad that they're not going to get to (2) and (3) on their own. Maybe they don't have those resources. Maybe the pit is too deep. At this point you take meds to get you to the point where you can build those habits that help you hit the point where you can get off them.
  7. A person can experience Category I and II throughout their lives, depending on the situation.
  8. Depressed People, Category III: You're definitely not Category I. You could have everything you need and the pit will never go away. You're not Category II, because the meds help--hopefully--but if you go off, the pit comes back. Something has happened in the body of a Category III person that will drag them down if the meds ever go away. And the meds aren't enough, they're never enough. You still need to learn how to achieve (2) and (3).
  9. Then there's even a scale in Category III. You could find a med that works for you forever. Hooray! Or you will have to change at some point--this is most people, the 'luck" is in how long the working regimen lasts). Or maybe it's the worst situation: a constant cycle of switching, never getting relief.
These are all extremely arbitrary categorizations, but the point I want to make is that Category I and II will never be III, save massive chemistry-changing trauma, and vice-versa. It doesn't mean that Category I & II can't, or don't experience the same level of depression as a III. I doubt my depression has ever reached the level of pain as, say, the most naturally happy person in the world who then loses a child.

This article mixes all of these people together. The fact that we've no idea what medications do doesn't mean they don't do something for some percentage of people. It would be fucking cruel to deny access to people who simply won't make it through the day without whatever mysterious thing the chemicals are doing to their brain. And expecting that Category III of people, especially the worse cases, to somehow be able to come off the meds when they get their shit together--and judge them when they can't--is monstrous and represents a fundamental misunderestanding of how different the world is for your brain and the brain of a person who is just going to suffer for this for the rest of their lives.

I went into and deleted my experiences. But let me tell you, I should be dead. In another lifetime, before medications, I would be dead. And that's just how it is. I was in a period where my life was as close to perfect as it could be when I first went on med, and if I hadn't I wouldn't be typing these words.

Yes, it is dangerous when psychiatrists for people like me start thinking the whole population needs to be treated the same way, i.e. meds forever. But it is fatal for anyone to think people like me just need to keep our chins up. If someone is experiencing liver failure you don't tell them to buck up and go for a run. My brain is in a constant state of failure. I can reach better places but pretending it's not the equivalent of a diabetic taking insulin is asking for the worst.

The problem I have with articles like this is that they feed into the existing narratives about mental illness. They provide fuel for the people who think "oh, well, eat better". We do need to have discussions about the necessity of medication and the length of that necessity, and whether someone is getting the therapy to implement the behaviors that will improve things. Which, by the way--everyone needs this, no matter who they are, and if your doctor gives you meds and sends you on your way without some sort of life support system then they're horribly irresponsible and bad at their job.

But if someone is careening downhill that is not really the time to say "Have you tried getting out more?"
posted by schroedinger at 12:23 PM on January 8 [36 favorites]


cooker girl, I wouldn't ever tell someone they should "never" take medication. I try not to offer my opinion at all, unless someone's really digging. I'm not a doctor. It's their decision and I don't see why my advice would be useful to anyone - there are too many differences between me and another person. I don't get that vibe from this thread either, I apologize if I came off accusatory.
posted by threementholsandafuneral at 12:43 PM on January 8


Now I'm told I'm not allowed to talk about my experience because it might discourage other people from trying medication!

This is very similar to the problem with privilege. I'm reading a book right now about the mental health ramifications of boarding school. It does a very careful job of recognizing both the privilege and the psychological harm privilege has, even on it's beneficiaries. Because at one time, even the most privileged person has been a vulnerable child molded to societal expectations.

But it's not a conversation point that belongs in most public discussions about class/gender/race because it sounds very similar to the stigmatized arguments that are propping up the status quo. The nuance means it's only digestible for a smaller audience where you have gained enough trust that you are part of Team Smash the Patriarchy. Metafilter might feel small(er) and safe(r). But if you are marginalized, you have less trust to extend.

I had to get through so much stigma to get to a place I was willing to medicate. So I'm wary of people who have anything negative about medication. That doesn't mean that your experience is invalid. It's just that until we hit equal footing where mental health has no stigma, I'm going to worry your decision to post this publicly does more harm (tilt the conversation against treatment and bolster anti-treatment views) than good (validate your personal experience).
posted by politikitty at 1:01 PM on January 8 [5 favorites]


One of the things that drives me crazy is the fallacious, vaguely anarcho-primitivist argument that goes, "scientists thought they understood how XXX worked, but it turns out that explanation was wrong! Therefore, the real problem is society, maaaan." It is not controversial that the "serotonin hypothesis" for anxiety/depression has been pretty thoroughly debunked, SSRIs have been somewhat oversold, therapy also works for these conditions, late capitalism sucks, and mental health is absolutely informed by experiences. None of that is evidence that antidepressants don't actually work, that they are a crutch, that they are covering up rather than treating the "real" problem, or that they are pacifying/sedating people when they should be helping to foment the revolution (as opposed to empowering them to live according to what they value). It's "clean eating" all over again.
posted by en forme de poire at 1:34 PM on January 8 [18 favorites]


I did read TFA but I also love when these threads become signposts for those seeking insight so I'll just summarize my experience with depression, which in my case is definitely at least comorbid with PTSD and has slowly morphed towards anxiety.

Phase 1, early 20s: I stopped functioning. At some point this became noticeable enough that I was put on Prozac after a brief hookup with amitriptyline. Two weeks later, on a course in Italy, my head figuratively exploded because for the first time in living memory I could see colour and taste flavour. I was so high on that experience that I nearly got sent home for being on drugs. It was decidedly pharmacological and I had NO IDEA that this was how ordinary human beings experienced life as opposed to this completely...flat...world. Highly recommend.

Phase 2: I never refilled that script, had a huge crash when I just went off the drug unsupervised, and then spent a lot of my 20s and early 30s trying to regain some of that ground. (I had retained the ability to see in colour, and I could sometimes gauge things by how much hot sauce I was pouring on things.) I did set about creating a life that worked for me, did lots of talk therapy, all of which helped a lot but what ended up being the equivalent of a drug was regular vigorous exercise, which is really annoying but regardless...for me is my needed drug. Also highly recommend. I needed the drug to set the bar but then I had to figure out my own path to the bar.

Phase 3: Grief hit and I had a grief depression. It was the same, but different. There was a real comfort for me in having such an easy explanation for it. It was the difference between being in a pit not knowing where you are or when you'll get out, and being in a pit knowing where you are and having some confidence you will get out of it. The pit sucked and had all the perils of the pit but in the moments that I could think, the thought was that at least there was a reason. Despite the fact that grief comes to all, I do not recommend.

Phase 4: I think now, in my later 40s, I am coming to agree a bit more with TFA that this too is an axis of depression that can be examined. I feel anxious and depressed sometimes and I know that it is related to some of the things I've experienced at work or see around me in society. I also see my kids and their friends struggling with stresses I did not have and how it impacts on them. I am glad we're talking about it, but I would like to create a world where society contributes more to individual welfare and less to individual anxiety and sadness.

Having said that, I realize that when I was in Finland, which provides a lot of things I think would ease stress here, I visited the Kamppi Chapel. I love that this chapel exists. But I am reminded that one reason it does (or at least so I was told, couldn't confirm this online at all) is to be a small part of addressing Finland's high suicide rate, so.
posted by warriorqueen at 1:38 PM on January 8 [3 favorites]


@schroedinger
YES YES YES
This is everything I didn't have the spoons to say.
posted by mkuhnell at 1:54 PM on January 8


The other thing that bothered me about this is how it talked about grief. What's wrong with seeking therapy, either talk or pharmacological, shortly after you experience a loss? What's wrong with taking steps to protect your mental health early? After all, we have grief counselors for a reason: grief is a really painful, difficult experience and sometimes it can lead to depression. And just because grief sometimes "naturally" leads to depression doesn't mean that depression is a necessary or morally correct part of grief: you can experience a lot of sadness and pain and anger and any number of other complicated emotions at someone's passing, without actually being depressed.

The article makes it sound like grief and depression are not distinguished at all in the DSM-V. This is simply untrue. FTA: "The DSM-5, to be published this May, eliminates this caveat, allowing someone to be diagnosed with depression two weeks after the death of a loved one. It includes some footnotes distinguishing depression from grief, however. Whereas depression is usually constant, grief is more likely to ebb and flow in waves and it does not usually invoke the feelings of worthlessness and low self-esteem that are so characteristic of depression. Grievers long to be reunited with someone they loved; the depressed often believe that they are unlovable. ... The DSM revision emerged from new studies confirming that bereavement is one of the most devastating forms of interpersonal loss and sometimes triggers a genuine depressive episode alongside grieving. Studies have also shown that people who are both grieving and depressed benefit from therapy and antidepressants."
posted by en forme de poire at 2:06 PM on January 8 [13 favorites]


For longer than humans have been human, we've used psychoactive substances to alter our own behavior. Even monkeys do this. Treating this as a somehow unnatural thing invented by Big Pharma is ahistorical and rejects part of what it is to be human. Of course there are many problems with the way antidepressants are prescribed, but claiming that depression is just about "unmet needs" is practically anti-patient.
posted by biogeo at 2:16 PM on January 8 [9 favorites]


Can we stop using crutches and braces as part of those weird metaphors for medication? Physically disabled people, of which I am also one, don't think of assistive technology as just some thing we're suffering through for a little while to catch up with able-bodied people, or something we're using temporarily. Crutches are awesome and braces are awesome and canes are awesome. Meds are also awesome! And I'm saying that as someone who has had the worst experience on various meds you can have, as a human.

Man reading this thread makes me so angry. Not necessarily at anyone in this thread, although there is a lot of bad science going on, but like. Being on ketamine, after failing 12 drugs, and having it work, is a thing that makes me feel like an alien on my best day in terms of watching these same boring debates happen over and over. There are different kinds of meds that work different ways in different bodies. This is not at all controversial in chemotherapy or what to take for a headache. It's really hard to care if people care if you take meds when the meds you take make even doctors squirm.

Having my experimental psychedelic I have pumped into my bi-weekly working, it's made me just. Done. With this kind of mental health discussion. People are dying. We are on our way to develop an ENTIRELY NEW CLASS OF DRUGS based on ketamine which have effectiveness rates as good as 90%, but that's happening slowly because of a great deal of ~stigma~ from doctors themselves and the FDA and a lack of awareness and research funding. Meanwhile we're not...doing anything else? Psych hospitals are still abusive, therapy is hard to get and often also abusive, people get prescribed SSRIs and they don't work and that's not even surprising because looooots more people don't respond to SSRIs than you'd think. The serotonin theory of depression has been debunked for a while. Some guy just discovered biomarkers for different types of depression, which is huge! Genetic testing, however rudimentary and imperfect it is, DOES exist now, and were it for another illness that would be a cause for celebration.

But we just keep having THIS SAME CONVERSATION over and over and I personally, as someone who could die from the severity of my illness, don't have time for it. I don't have time for NAMI doing an awareness march when some celebrity could dump billions of dollars towards research and get us a little closer to where we're supposed to be. I feel the ticking clock. Take meds, don't take meds, do whatever you want. Of course depression is caused by both environmental and chemical factors and everyone needs different treatment!!!! But the world of mental health is moving on, and metafilter is not? I don't know. It shouldn't be shocking that medicine is complicated, what bothers me now is we seem to not want to move on from that to new things for years.
posted by colorblock sock at 2:49 PM on January 8 [21 favorites]


Is everything Johann Hari knows about depression wrong?

tl;dr, Hari sets up a straw man argument and cherrypicks experts to support it.
posted by smoke at 4:55 PM on January 8 [4 favorites]


We are on our way to develop an ENTIRELY NEW CLASS OF DRUGS based on ketamine which have effectiveness rates as good as 90%, but that's happening slowly because of a great deal of ~stigma~ from doctors themselves and the FDA and a lack of awareness and research funding

For what it's worth, my direct experience has been that NIH and other funding agencies are actually quite interested in funding research on ketamine as a treatment for various neuropsychiatric problems. Research is hard and slow, and the path from promising case study to reliable therapy is very, very long. But people are traveling that path right now, and funding agencies are spending money to make it happen.
posted by biogeo at 6:06 PM on January 8 [4 favorites]


Can we stop using crutches and braces as part of those weird metaphors for medication? Physically disabled people, of which I am also one, don't think of assistive technology as just some thing we're suffering through for a little while to catch up with able-bodied people, or something we're using temporarily. Crutches are awesome and braces are awesome and canes are awesome.

Really well said -- thanks for making this point, and my apologies for using that language in this thread!
posted by en forme de poire at 6:09 PM on January 8 [8 favorites]


Physically disabled people, of which I am also one, don't think of assistive technology as just some thing we're suffering through for a little while to catch up with able-bodied people, or something we're using temporarily. Crutches are awesome and braces are awesome and canes are awesome.

And for the many people who have been using SSRIs successfully for years and whose lives are made worse when they stop, antidepressants are likewise awesome. Why would one not file them under "assistive technologies" and just take it as a given that different people benefit from assistance for different lengths of time?
posted by flabdablet at 8:29 PM on January 8 [8 favorites]


I'm sorry if I misrepresented myself: I absolutely think SSRIs are assistive technologies, as are all meds, and they're likewise awesome when they work.
posted by colorblock sock at 9:43 PM on January 8 [3 favorites]


I was expecting a vapid article, but each of the experts the author cited seem fine to me. Like even:

"In its official statement for World Health Day in 2017, the United Nations reviewed the best evidence and concluded that “the dominant biomedical narrative of depression” is based on “biased and selective use of research outcomes” that “must be abandoned”. We need to move from “focusing on ‘chemical imbalances’”, they said, to focusing more on “power imbalances”."

I think that's a great progressive tidbit right there. The story about the DSM/grief, the story about the (unverified) cow, those are just interesting to think about and I'd not heard of them. It's okay to think about stuff, nobody is asking readers to be unskeptical.

I thought the other article had irrelevant criticisms in the first half and then got pretty disgusting. Maybe a neuroscientist in psychiatry, given their specialization, isn't automagically trained to talk about social science issues (which, if they were trying to discredit Hari by pointing out their prior plagiarism didn't point out his educational pedigree which was in Political and Social Sciences from Cambridge). From the other article:

"Perhaps reliance on antidepressants is due to incredible pressures of time, money and workload on medical professionals, and alternative treatments require many hours of one-on-one interaction with trained experts, rather than swallowing a few capsules a week?"

So, um, actually, rather than admit that there exists a very critical point to be made, make an excuse of "We doctors are incredibly busy, so let's clumsily reinforce the classist narrative that one intervention is more cost-effective than the other" and explicitly insinuate in the next sentence that his media/ideological opponent is merely a conspiracy theorist.

And seriously, Guardian bears some fault in stirring this tiresome debate.
posted by polymodus at 9:57 PM on January 8


Hari’s method of presenting that UN document is fairly misleading, because he presents it as a collective opinion (“official statement”) made and adopted by the UN as a whole or by some panel within the UN. In fact, it’s a report of the UN special rapporteur on health, an individual expert who is putting his own view on mental health before the UN and who is not a UN employee.

The special rapporteur’s view is that there is a significant imbalance between biomedical and social conceptions of disability, particularly in the realm of mental health, and this has crucial implications for how states should change to fulfil their obligation to respect the human right to health. I think this is a compelling argument (though I also think it’s dishonest or ignorant to present it as some kind of “official view” of the UN itself, as opposed to one expert’s well-reasoned opinion within a larger controversy). His argument does not suggest, even by implication, that individual patients should abandon medication and focus on finding meaning in their lives instead; his focus is precisely on the obligation of states to deliver a social order that fosters mental health (as one would expect from anyone with a mandate from the UN). If Hari’s piece had been about the state and its responsibilities, instead of being about individuals and how medication doesn’t help them, it would have been more interesting and less dangerous. Perhaps the book redresses this and focuses more on how social and political systems in the UK starve people of what they need and less on the individual journey away from medication and towards personal fulfilment. But his framing of it in this one article doesn’t get that balance right.
posted by Aravis76 at 1:43 AM on January 9 [9 favorites]


For what it's worth, my direct experience has been that NIH and other funding agencies are actually quite interested in funding research on ketamine as a treatment for various neuropsychiatric problems

Exactly.

Also, there are clinical trials of it happening all the time; if one is nearby it could be an opportunity to try it.

I want to try ketamine--but I want to try it if it WORKS. There is a lot of positive anecdotal evidence, and then you dig deeper and the methods by which people are obtaining and taking ketamine if all over the place. A lot of people taking it orally (as opposed to IV infusion) and at significantly higher doses. Which is not so much benefiting from the theoretical benefits of ketamine as it is just getting high. Dose matters a LOT and more is not better. Which is one of the reasons there is so much research being done on it.
posted by schroedinger at 4:28 PM on January 9 [4 favorites]


The research on propanolol and PTSD is also super interesting to me - it apparently interferes specifically with the heightened emotional response associated with a traumatic memory being accessed, but not with factual recall of the event.
posted by en forme de poire at 11:42 PM on January 9 [2 favorites]


braces are awesome

Are there multiple uses of "braces"? I thought that reference was to orthodontic braces, which I've only known to be a temporary device - are they permanent for some people?
posted by the agents of KAOS at 1:40 AM on January 10


Yes there are. Google something like "leg brace" to be introduced to the world of orthotics.
posted by Dysk at 2:30 AM on January 10


I read the book. The article misrepresents the meat of his argument - he's actually looking in some depth at potential root causes for depression and what the potential options are. It's a sobering read but there are some interesting insights. He does a lot of digging into the effects of advertising and capitalism and the rise of individualism. Also, that reference to Amish farmers is not an advocacy position - the book explores the dark side of community cohesion in mono-cultures, and how silencing and othering feeds depression.

It's not a perfect thesis, there's a bit too much focus on the utopia of rural collectivism for me, and his subjectivity is writ very large in some parts but as someone with medicated GAD, it gave me much pause for thought and lots to reflect on.
posted by freya_lamb at 11:56 AM on February 4 [3 favorites]


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