Re; #3, apparently the cut-off for anemia is too low, currently. Most people who are in the 'low but still normal' range for iron experience significant symptoms, so could benefit from further inquiry into why their iron is low and/or supplementation.
I'm not trying to be snarky, this is a genuine question: Does that mean that a homophobic right-wing depressed patient should see a homophobic right-wing therapist?
I used "homophobic right-wing" because, by reversing the example used in a directory contrary to conventional morality, it reveals tensions between different criteria for a therapist. I can think of 4 criteria that might be in tension:
1. A therapist should ideally have the same worldview and moral beliefs as the patient.
2. A therapist should ideally have dealt with (or be dealing with) the same mental "disease" as the patient.
3. A therapist should have the conventional morality of the patient's culture, to help that patient better fit in and attain what's regarded as "wellness" by that culture.
4. A therapist should have an objectively healthy worldview and morality, and be free of any mental disease, in order to guide the patient in an objectively good direction.
To me, it seems like each of these are important. But they can directly conflict with each other; and each feels very wrong to me in some circumstances. The profession thinks it's addressed these issues, but maybe all it's done is privilege the dominant culture in the same way it did in the past. In the view from inside a culture, using only criterion #3 would feel like using all 4, because we choose examples which address the problems we ourselves perceive as most worthy of attention.
I agree with previous poster, the actual beliefs and attitudes of the therapist are less relevant than whether the patient FEELS understood and that the therapy approach suggested fits them well.
And sometimes 'personal chemistry' is mysterious - which just means too complex or non-obvious to easily figure out.
I've spent many years treating some patients whose politics/values were VERY different from mine, quite successfully. I'm sure that within a few months or a year they had figured out I was not a 'match' for them in that way. But we worked together with mutual respect, I helped them figure out how to live within THEIR values (and gently challenged a few things that seemed inconsistent value-wise while quite consistent 'tribally'), and all was well.
My experience is that, before 2016, shared beliefs and interests seemed to have little correlation with how well I got along with someone. Shared epistemology and curiosity might have correlated with that.
For the purposes of useful medical attention and the best chance of recovery, the answer may be a tentative yes.
Although it sounds a bit distasteful when you put it like that.
One way to look at it is that for the best chance of a medical professional and a patient being willing and able to work as a team, they need to have at least some underlying beliefs and values in common. Plus, the patient needs to be confident that they can be open and, yes, even vulnerable to the medical professional.
This is not as likely to happen if there are significant differences in their foundational beliefs. That's not to say that it can't happen; just that it is less likely.
The problem pyentropy mentioned above, about smart analytical children becoming severely disillusioned by their therapists is a real one (and it isn't confined to children, either).
I think sort of yes, but it's just a proxy. For this kind of therapy I think the real crux is whether the therapist "gets" the patient in a way that the patient feels "gotten," by which I mean the patient can (hopefully correctly) sense that the therapist understands their values and motivations and situation and is an ally in supporting them in a way that respects and accounts for them as a person, ie. on both a practical and identity level.
I think by default you get that kind of compatibility when you really do happen to share a worldview, but it's not a necessary condition: a skilled therapist can and will do all these things and cause the patient to correctly sense they can and will do all these things, even if the therapist is totally different from them.
Homophobic right wingers can be great therapists too, the last psychiatrist (see the blog) is a great example, and even Scott vouches for him as an inspiration in terms of pharmacology and Freudian psychotherapy.
Was TLP homophobic or all that far right? I remember some spicy takes on the transgendered (that stopped short of outright denunciation (and some crimes of writing style (such as these nested parentheses))) , but can't remember if he had anything negative to say about gay people.
If you really believe TLP was either homophobic or far right I'd like to just point out that he routinely switched implied genders and wrote contradictory personal anecdotes, specifically to keep people in the dark about his identity and personal beliefs.
Thanks for this post. As a patient in my 20s I found the psychiatrist uninterested in understanding and unable to know about what I wanted to get better *for*. Being frantic at a disconnection from one’s gift is sort of just more BS to some docs. I think Scott is an exception to this.
Later in life after getting bonked in the head I was taking some kind of “arrange the tiles” test. I got some but then screwed up. The examiner said, you did really well, as for the ones you missed, only engineers get those right. She smiled at me. I expect to remember that as long as I live!
High performance is sometimes thought of as some type of gravy on the meatloaf of life. I don’t really get there anymore but I remember when that WAS the meatloaf. You are right, child psychiatry is kind of a minefield. I hope we move toward a society with more awareness of subtle aspects of mental wellness. I think it’s easier to heal little problems before they get big, but they have to be noticed first.
You’re not wrong about getting sick/older, it does happen to people all the time. Change and loss are part of life, that’s true too. Good treatment is also hard to find. If you can access a doctor a good holistic practitioner might be a good direction. I may be done with talk therapy, I had EMDR for a few years about 15 years ago and it really helped, I got some function back, then I went and made more choices and blew even more. Went into a talk therapist’s office two years ago and left feeling undeserving. Later that day she sent me a text declining to work with me, haha. Not everything is addresssble in speech. I had two sessions of chakra clearing a decade ago that did more in a few hours than talking did in hundreds of hours. A few chi gung exercises really helped but I forgot a detail and can’t find the description. Also taking certain foods out of my diet (peanuts, some additives) lessened the internal stress; getting a CPAP for the sleep apnea helped clarity; thyroid supplement; treating the background ADD; beginning a recovery practice and submitting to an ever-evolving pile of pills and vitamins. Also learning to seal aura/close energy. If you ever decide to pursue healing modalities again there might be something out there that wouldn’t be a net negative for you. In my early 20s I let it ride but untended it got worse rather than stay steadily bad, so for me I have to be active. Close to 50 now and some doors are finally creaking open again.
If being intentional about healing creates a feeling of stripped gears or disempowerment, personally I take that as a sign to change the pills. “Effort makes it worse” is not too far from suicidality for me and I try to stay out of that zone. I never liked the diabetes metaphor of mental struggle, I prefer a “knee injury” model; I may need a brace for the rest of my life, or so to speak a mobility scooter, but I don’t have to give up going from place to place.
I’ve seen people feel like hell from undiagnosed Lyme disease or Epstein-Barr virus and feel better with treatment, too, so whatever “it” is isn’t always depression.
I'll make a wild and insensitive guess here: Try seeing a southeast Asian therapist. Western culture is firmly mired in the incoherent Platonist concept of "perfection". This justifies the Western idea that it's immoral for doctors to try to make patients "better than well", where "well" means "average". It's seen as hubris, as trying to rise above your place in the Great Chain of Being.
This Western obsession with perfection, not just as an aspiration, but also as an obligatory moral limit on aspirations ("flying too close to the sun"), may be why surveys have shown ( https://www.liebertpub.com/doi/full/10.1089/hum.2019.197 ) that Asians are more open to gene therapy than Westerners. It may also explain why Western fiction characters are usually based on "flaws" (deviations from perfection). Buddhism and Hinduism also have the concept of "perfection" at their roots, but Asian and Indian heroes can, like the anime and videogame heroes introduced from Japan, always level up (maybe even after attaining enlightenment). Bollywood movies don't have "superheroes" (aliens or genetic mutants who are literally super-human). Instead, they have humans who are just MUCH better at everything than average humans.
In particular, there's bipolar 2, a sort of bipolar where the manic part is very small. One of my friends got snagged by that one-- if you have bipolar 2, treatment for depression can make the depression worse. I think one of the symptoms of the manic phase is racing thoughts, but this should be researched.
It's preliminary, but also a very benign intervention if you just tell someone to try and eat more probiotics. Very limited risk there, unless you're lactose intolerant I suppose...
Lots of non-dairy probiotics out there, fortunately! It does take extra looking to find them, sometimes, though. I get Bio-K liquid, soy based (yummy mango flavour).
The “cures... reliably” part made me wish doctors did this more often. Preventing the trail of damage created by depression might be worth a little hole in the skull.
This, but unironically. I keep saying I want to try ECT and my psychiatrist, who last looked into it 30 years ago, basically has fits of revulsion and more or less says "hell no." I need a referral. Maybe it's time to try another doctor.
Having a baby makes lifestyle changes, showing up to therapy appointments, and (if you're breastfeeding) medication usage more difficult and thus is probably not Intro-Level Treating Depression.
Well, life comes at you fast sometimes. If Scott doesn't feel like he can address post-partum depression well, then he probably shouldn't try, but it's a phenomenon that women deal with every single day. Both the lack of slack to try changes in lifestyle (it's still hard for me to find time to exercise with a 5-year-old) and the cultural valences around how motherhood should make a woman feel happy & fulfilled make offering a lifeline and a sense that post-partum depression can be treated of particular value. I imagine that both of those factors make that kind of depression feel particularly suffocating and paralyzing.
I agree with you- this seems like a major oversight. I also know women who experienced depression after a lost or terminated pregnancy, not just because of the circumstances, but also because of the hormonal fallout.
s-adenosyl-methionine-e doesn't appear to be listed in the BNF, and you can buy at least one brand of SAM-e on Amazon UK, so I don't think it's prescription-only in the UK, at least.
My main initial reaction is: who is the target audience for this? As a nerdy SSC/ACT fan I love it as a ‘much more then you ever wanted to know’ post, but I’m not sure how, say, a person wondering if they might be suffering from depression would read this?
This was my question too. I'm assuming the audience at Lorien Psychiatry is generally people who are *not* SSC/ACT readers and who have come to the site looking for clinical mental health information when they may have very little prior experience with diagnosis or treatment.
As such, there's a bit of a thread of "trust your intuition" and "you'll just know" that I think you need to tee up first -- this (presumed) audience may be used to looking to a clinical website specifically because they want someone to tell them The Answer to their problem. The thing that you're offering that is different is the idea that with the information you are giving them, people might be able to figure out The Answer themselves, but I think you need to frame that first as it may not be a familiar concept.
Relatedly, I found the pronoun switching distracting -- sometimes you talk to the reader as "you", but sometimes you are talking about someone who.is not your reader ("they"); and sometimes you're "I" and sometimes you're "we". I think it might work to just stick to "you" and "we", and you can perhaps footnote the "I" statements which tend to be you (Scott) basically being the source/reference for whatever statement you're making.
I got stuck right at the beginning with a sentence in the second paragraph and suggest some changes: "Chronically depressed people live almost a decade less than non-depressed people, and there’s increasing evidence that this isn’t just because... " should really be "may live almost a decade less" if you're only going to link to the single study. It would be better if you can find several studies that show different reductions in life span, in which case you might say something like "...may live xx to yy years less.." and provide a couple of links. I just don't like being super declarative based on a a study where a third of the participants were age 50 in 1952. For the second clause, "increasing evidence..." links to a single study from 2001 -- it would be better if you could layer a couple of more recent citations there to support that statement.
Typo: The following sentence from 2.1 repeats 'enough' and uses 'give' instead of 'gives': "If you have zero willpower, not enough enough to be the seed for a tiny investment, then you should start with medication and only pursue willpower-requiring strategies if the medication give you that first little seed of willpower."
I wonder whether another format for copy-editing would be superior, such as a wiki or github that commenters can propose edits to, but only Scott can approve them.
This is a very good suggestion. I am a copy editor, and would happily do this for free, but copy/pasting errors is just too time-consuming. I imagine also on Scott's end, making use of the corrections.
How nerdy/STEM-educated/comfortable with technical vocabulary do you expect the audience for this page to be? I enjoyed the discussion of depression as an attractor state in a dynamical system, for example, and enjoyed your longer post on that too; but for someone less mathematically inclined, I worry it might seem so jargon-y or academic as to make them less likely to read on. I unfortunately don't have good enough theory of mind about non-mathematically-inclined people to tell whether this is a justified worry. But I do recommend that if you want this to be attractive, engaging reading for people less nerdy than the typical SSC reader, you should seek out some such people to give you feedback.
I really enjoyed reading this introduction to the management of depression, and consider it to be one of the best I have encountered.
However I suspect that many actually depressed people/people outside of the ACX sphere would find some of the language and thought-processes challenging. Although this is mitigated in some areas by explicitly explaining the process, as with the explanation of priors early on.
It's important to keep in mind that average reading age is still hovering around that of a bright 12 year old, and it seems likely that even a bright 12 year old would get bogged down at some points in this discussion.
That said, there is a lot of good, clear and well explained material here. Scott's efforts to be both comprehensive and lucid are very much in evidence.
Might this actually be a good thing? I suspect that the sort of person who'd read this, while perhaps not familiar with dynamic attractor systems or whatever, will find these sort of words to be at least a breath of fresh air compared to the usual CBT-derived pop-psych that shows up when you google the issue, to say nothing of the endless deluge of Top N Things to Do When You're Depressed.
I don't know if it's just me, but I tend to slot math-y and social science-y terms I don't understand into different mental buckets - "complicated, but rigorously investigated concept", and "ah, the humanities are at it again..." respectively.
I'm not sure that I count as "non-mathematically-inclined", but for reference I don't care for chess and failed College Algebra at least 3 times. My education is a couple of years as a philosophy major before dropping out. I'm better at math now (mostly stats stuff for work), and I do some light coding (mostly JavaScript), but I'm not math-inclined. I think the level of technical terms is about right.
I'm going to have my wife (degree in speech-language pathology) and sister (masters of library science) give it a read as well; they're less tech nerd than I am, so I'm interested in that feedback.
I think the structure is very helpful; you can skip a lot of the explanation and scan up and down pretty easily. I especially like the "stuff to try" section; easy to read. Might help to link back to details on the medications above? The best thing is that it's probably the most straightforward single page I've read on MDD, with a good overview of the state of things and clear recommendations, backed up well with good sources.
I found the first paragraph that mentioned the attractor state paradigm felt somewhat out of place. It isn't a concept most readers would be familiar with, and although probably interesting to a lot of readers, it also doesn't provide enough detail to understand what it's talking about. I would suggest at least adding a link to the longer discussion on the topic--otherwise bringing it up just adds confusion and wastes the reader's time.
Agreed, the "attractor state in a dynamical system" piece threw me too. I appreciated the analogy, and yes, it did clarify things for me... but... I happen to at least have heard of the concepts of "attractor" and "dynamical system" (heard of, never actually calculated, mind you). I can't name any of my friends who can say the same.
I'm a practicing mental health professional (clin psychologist in Aus) with a PhD in modelling cognitive processes. I can guarantee you are right. I spend a fair bit of time translating what GPs (Physicians) and Psychiatrists say to clients, and what clients read online.
We have a pretty good NFP in Australia called black dog institute which has some good MH resources. It is pitched at a typical client level. I often send ppl there.
FWIW, I do not do dynamic systems, but I think there was something bit off with the language about attractor states. While the overall point made sense to me because I have read the ACX post where the idea was first discussed, I could have not parsed the paragraph's meaning without that context.
Specifically the irksome parts were here:
>On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
I think in applied mathematics people prefer to say that the "mathematical level" of the dynamical system *models* the physical ground reality. Especially so if the dynamic system in question has inputs from as different categories as biochemistry and life events.
Also, what edges, which graph. One can combine dynamics and graph approaches but it is not immediately obvious to me how? Again, re-reading the original dynamics idea post helps: https://astralcodexten.substack.com/p/ontology-of-psychiatric-conditions-34e the graph probably refers to the graph representation of correlations between the symptoms.
Trying to bring up neuroendocrinology objectively in the modern era is unfortunately frequently academic self-immolation- but I think it might be worth it. Eg NDRIs and testosterone, PMDD and temporal SSRI scrips
Just as a first pass-mainly cause my startup just got a deal with Sage/Biogen and they have some of the first endocrine based treatments
Testosterone has a large antidepressant effect. Perhaps this accounts for the difference in prevalence of depression between men and women. Most people don't get enough zinc, magnesium, and vitamin D and can raise their testosterone a bit by getting more of that and lifting.
My PubPeer plugin tells me you're quoting an article which has a worrying comment on PubPeer (the comment is from a bot which outputs warnings when the summary statistics seem weird, and should probably be checked). Weirdly, I can't find the relevant link in your article right now, but here is the comment if you want to check: Updating positive and negative stimuli in working memory in depression (https://pubpeer.com/publications/0DD5CCD0457CAF07AAB1E74607D109)
One thing that's helped my wife is consumption of a sugar called inositol, which is about half as sweet as glucose, IIRC. It helps with rather specific types of depression. An issue with inositol is intestinal absorption which limits the amounts used in some studies or dietary compliance. But alpha-lactalbumin assists with asborption to some extent. Alpha-lactalbumin is a component of whey.
One of the effects of lithium in people with bipolar disorder is to reduce inositol concentration in parts of the brain.
Probably without. It's an abbreviation of S-adenosyl methionine, and I think it originates from the 3-letter code for methionine, which is Met. So it should probably be "SAMet" but "SAMe" is better than "SAM-e" which doesn't really make sense. Since it functions biochemically most often as a supplier of methyl groups ("Me" groups) this also makes a little more sense chemically.
On the other hand, if you google "SAMe" you will get about a billion hits that think you were typing the word "same" so...maybe "SAM-e" helps get you through the mindless algorithms.
You seem to hint at the idea that depression that comes from anxiety is different. How would you approach it differently? And is it not common for depression to not be tied with anxiety? ( thought they were frequently comorbid.
Depression is sometimes the result of a vicious cycle of failure causing low self-esteem causing failure. Methylphenidate works surprisingly well for escaping the cycle.
Foods high in carbs reliably give me brain fog, anxiety, and short-term depression for hours after eating, so the mediterranean diet recommendation would make my depression worse. Fruits and meats don't have these issues for me. If anyone can diagnose my dietary condition based on this description, please do.
Have you tried cutting gluten from your diet? I’m guessing the answer is yes given the popularity of gluten free diets, but if specifically the issue is carbs high in gluten (mostly wheat products, some other things) that would make some sense for Celiacs disease.
Google tells me rice is gluten-free, but rice is one of the worst offenders for me. To completely eliminate the possibility I should probably find a low-carb source of gluten and try it with meat. Eating lots of carbs seems to cause low-level inflammation all over the body e.g. muscle and joint aches. I seem to have a problem with specific types of carbs as I can handle fruits just fine. My best guess is that some sort of filtering process in my body is not working properly. My genes are from populations, which do not have a long history of eating grains.
In relation to Scott's portion of nutrition, I was also somewhat surprised by this endorsement. I think this section could use a little more elaboration, particularly on the connection between inflammation and depressive-symptoms.
I'm tentative to include this because, like Scott mentions, the research is pretty shoddy and already scarce, but I think it would be worth considering adding a brief introduction to an elimination diet for people that may be experiencing adverse bio-psycho symptoms due to some unknown product they're consuming. This isn't intended to be even a tacit endorsement of the ketogenic or carnivore diets, especially considering how each sub-community of the low-card tribe is so vitriolic to one another despite the fact that they're unified in their lack of established science. With that being said, there's enough anecdata to suggest that there's something worth investigating.
My only concern with this ties into a central theme of Scott's writing here, which is that modifying one's nutritional approach can be hard, especially if one were to endeavor on something like the keto diet. This can then perpetuate the self-defeating cycle of depression, which just makes things worse. Any thoughts on this?
Re. "You can address the social causes by changing your life circumstances (and research suggests people underestimate the potential benefits of making major life changes)."
This is more true if by "people" you mean psychologists. I had severe depression in the years around 2000, and it recurs when bad things happen in my life. I wrote psychologists off forever after several attempts, because whenever I talked about what I saw as my life-circumstance problems, they would try to get me to think or feel about them differently. They tried to talk me out of my attempts to remove what I saw as the causes of my depression. They said that the belief that improvements in your circumstances would make you happier was a trap, like thinking that earning more money could make you happier.
In related news, earning more money can make you happier.
Sorry you had to deal with that! Glad you managed to break out of it, or at least see through it!
That said, I think this is plenty true even if one just means non-psychologist people. As a data point, when I rearranged my life while being B12 deficient (and oblivious to it) and very depressed, I was *expecting* those changes to make a big difference, *and they still made a significantly bigger difference* than I had been expecting them to make. Since I don't actually know anyone who is more generally-optimistic than I am, I absolutely believe that this is a common tripwire.
Wow, sorry to hear you met so many crap psychologists! Any noticeable factors that would indicate which to stay away from; were they young (and therefore perhaps inexperienced)? What level of training, type of training?
Well, they used cognitive behavioral therapy (CBT), which was all the rage then. But also, "several attempts" here only included 2 multiple-visit attempts, and only 1 that was more than a month in length. After that, I found a really shady psychiatrist who did nothing but prescribe pills to Vietnamese patients (plus me). She prescribed me bupropion after a 5-minute visit, and that worked so well that I didn't bother with psychologists anymore.
I seem unable to be depressed for more than one day. This might happen once, maybe twice in a year. My strategy for that day is basically to stay in bed and eat potato chips. Next day I'm back to normal. Is there something wrong with me?
Congratulations, for your free prize please accept this smack in the chops.
I do get the impulse to make a joke about this; after all, doesn't every one feel a bit down, a bit blue, now and again? What's with this "oh I'm depressed" craze? After all, if going for a walk in the fresh air makes you feel better (Official Medical Advice), isn't the reasonable thing to just say "pull yourself together" instead of indulging in notions of "no, this is depression"?
When you've literally slept for 36 hours straight because you are too dazed to drag yourself out of bed (except to the bathroom and then fall straight back into bed), come on here and talk about how staying in bed resets you back to normal.
I don't know. Most people are probably immune a lot of the time, but some people don't get depressed even when it would seem likely considering their circumstances.
Depression is a maladaptive human response, not a normal or inevitable one; neither is it a communicable disease, per se, so it seems odd to speak of "immunity" in this context.
I think the “what is depression” section to be pretty jargon heavy. I’m a medical student, and if I ever heard someone say “psychomotor” in one of our exam practice sessions I’d call them out on it because patients don’t know a lot of the words that we get taught, or at least aren’t able to figure out on the fly. For instance, I recently saw some paediatric cardiologists tell a parent that their kid’s aortic valve was prolapsing into hole in their heart. I appreciate they said “hole” rather than “ventral septal defect”, but I’ve never heard the word “prolapsing” outside a medical context, and lots of people don’t remember their high school biology cardiac anatomy enough to know what an aorta is or how valves work.
I could just be underestimating my patients, but I’d try to use more accessible language in that section at least
I expect Scott's posts, even at Lorien, will always end up best for people who have bigger vocabularies than average, and more tolerance for jargon. But in particular I would suggest that "psychomotor retardation" is a phrase that's likely to cause a lot of confusion and misunderstanding, and I would probably at least reverse that bullet. (That is, start the bullet with something like (from Wikipedia:) "visible slowing of physical and emotional reactions". Then if you want to include the jargon term, do it in the parenthetical, rather than the reverse.) Normally I'd expect people to be able to deal with the "jargon (explanation)" format, but "retardation" is a word whose technical meaning is almost unheard of in common parlance, and whose colloquial meaning is very emotionally charged.
I’d saw some links on how anti-inflammatory drugs can be used to treat depression. Twitter search: @degenrolf depression or @degenrolf anti-inflammatory is where I found it
Depression in men is one of the symptoms of low testosterone and testosterone levels have been falling 1% every year for a long time now, so it's possible that a lot of male depression is due to low testosterone.
The problem is made much worse, because most labs (at least here in Europe) don't have age-adjusted ranges for "normal values", so a 20 year old guy would have to have the testosterone level of a 90 year old suffering from erectile dysfunction before a diagnosis of low testosterone is made and supplementation is offered.
I talked to a medical doctor about this. He is recognized as a leading authority on these issues here in Estonia and is often in the news. He said that falling male testosterone levels are good for society and therefore he and his colleagues have decided to only treat cases, where low testosterone directly and clearly affects reproductive health. Depression and other less important symptoms he leaves to other doctors.
I also suspect much of it is due to hormonal problems. Very foolish that he and his colleagues believe this, there is more that comes of high testosterone than youthful aggression.
My sense is that Western low testosterone is overdetermined. If I had to guess though, the main contributors are EDCs, mentality, stress (resilience), and obesity/exercise. Treatment modalities might be:
- EDCS: eliminating all synthetic toiletries, eating organic, washing hands frequently and not mouthing them (apparently common), if in USA reducing meat consumption generally (atrazine is really bad and gets into almost all animal fat from the water table, organically fed or not) in favor of fish, and finally slowly replacing all plastics and synthetics that one touches / stores food & drink in with cotton/ceramic/steel/etc.
- Mentality: I'm pro-feminism but I think it's fair to say that it has led many men to adopt lifestyle choices (eschewing overt status, favoring collaboration over competition, being more relational and empathetic, socializing with women) which all empericially decrease testosterone. My POV is that Western men should keep the feminism, but become "feminized" at their peril — our society had norms against men adopting these behaviors for a reason.
- Stress: I doubt stressors have changed much, but many have become much worse at weathering them. Say what you will about the "Flying Spaghetti Monster" and the value of individualism, decreases in religious practice, communal bonds, and family closeness seriously injure resilience to stress. Additionally, many young people have been raised in protective environments where responding to stressors histrionically is rewarded — not good for resilience. I know many dislike religion because they don't want to accept the truth claims, but IMO most unbelievers would still get big benefits if they just went to the Church/synagogue/etc they were raised in once a week and did the rituals. For those who were raised atheist, I bet Jungian active imagination/etc would work, you'd just need to find people to go along w it (apparently in the 90s this was popular, guys would get together and dance in the forest talking about archetypes under the auspices of the Mytho-poetic mens movement). If not, some of the more woo-ish meditation traditions probably would work.
- Exercise/obesity: It's well-known that visceral fat leads to testosterone decreases, and endurance training and resistance training both probably lead to modest improvements either via decreasing fat or just by decreasing stress or possibly via some other idiosyncratic mechanism (skeptical of the latter personally).
I realize a lot of these recommendations seem less than politically neutral — the recommendations all quite right-wing adjacent. I don't think this is a bias on my part, I actually think that for men testosterone seems to have a causal role in influencing politics. There are some studies that validate this, but for me it is anecdotally obvious. Very rarely have I met a man with traits of low testosterone who has been right wing, and the converse is even less common.
> He said that falling male testosterone levels are good for society and therefore he and his colleagues have decided to only treat cases, where low testosterone directly and clearly affects reproductive health.
WTF? I'm baffled as to how a medical doctor feels he has sufficient expertise, let alone the right, to enforce that kind of conclusion. Doctors should be concerned with health.
It may be worthwhile to add a section on ways to help prevent depression from occurring in the first place. That's one of my concerns as a fairly neurotypical person; I really would like to not become depressed, since the condition works against you seeking out ways to improve yourself.
cutting out soda might result in caffeine withdrawal (some people who drink a lot of soda all day), which could make depression or anxious symptoms worse in the short term.
maybe worth warning about this and suggesting green tea or something?
Whoa, now you're playing hard mode. Nice read! Some comments mostly on the non-medical parts:
I'm not quite sure why you are treating hypomania as a bad thing in 1.2.1 (at least the sort that contents itself with messing with one's emotions rather than encroaching on one's perception). I'm aware of the specific problem with suicidal people getting more likely to try it out when out of depression, but should the rest of us worry? If I am to name what's wrong with the world, overconfidence isn't what comes to mind. But I guess there are some things that become hard to say once one calls oneself a doctor (thank goodness a PhD does not count).
I wasn't aware of the Levitt study you referenced in 2.1.1. That might be useful not just for the depressed? At a quick glance ( https://www.nber.org/system/files/working_papers/w22487/w22487.pdf ), there does appear to be a selection bias issue here: a study on Freakonomics and MR readers will necessarily have a certain kind of slant that may make its conclusions -- such as the incredibly high happiness returns on starting a business -- somewhat less generalizable than one might hope for. Still, if there is an effect here, yolotherapy might be the next big thing. (Though oracles and fortunetellers might have been living off the same land for millenia; this study should be lauded for observing the same effect in some of the groups least likely to use the services of the former.)
Mediterranean diet. Someone is going to retweet the hell out of this.
2.1.3: In my experience with something-like-depression (I think there should be an IANAL-like disclaimer for discussions of undiagnosed psychological symptoms, particularly when one doesn't even believe one has the real thing), I found hiking helpful... for the duration of the hike. The effect dissipated on return, probably because of the transient nature of the whole thing. On the other hand, far-from-wholesome nerd work (think coding until 5AM) worked like a charm if there was something tangible to show at the end. Neither to generalize nor to pollute the data, but I feel that there is some kind of internal accounting of accomplishment and progress involved that is not easily tricked. Maybe serious gamification (Pokemon Go?) could help, but unless you manage to forget the artificiality and sideshow-ness of the attained achievements, it's likely to be a hard sell to the "you suck" mob inside your mind. (Preemptive "don't worry about me" to the commenters here; I am doing fine and my symptoms have always been subclinical.)
2.3: "If neither of them work, and you’re feeling optimistic" hehe.
I'd have wished for some discussion of tolerance in 2.3 and 2.4. Is it less of a thing than I expect it to be, or is less about it known?
Typos: "pasTTimes" (did the proximity to "hoBBies" lead you astray here?), "refriDgerator" (wouldn't have spotted this one if the "d" didn't stand out so awkwardly in a Latin root), missing period after "hardest to do it anyway", "only proportional" (should probably be "proportionally"), "enough enough".
>I'm not quite sure why you are treating hypomania as a bad thing in 1.2.1 (at least the sort that contents itself with messing with one's emotions rather than encroaching on one's perception). I'm aware of the specific problem with suicidal people getting more likely to try it out when out of depression, but should the rest of us worry? If I am to name what's wrong with the world, overconfidence isn't what comes to mind.
Hypomania isn't just overconfidence. It's a pattern of being insensitive to the risks or costs of one's actions, along with, yes, overconfidence and a strong drive to achieve and to try new things. Yes, it can be fun, but it can also lead to a lot of pretty horrible consequences that the manic person will end up regretting. Arrests, divorce, going into debt, getting fired, are all possibilities.
Well, all of these seem to have a greater upside according to the recommendations given in 2.1.1. Of course, there is an optimum in the middle here, but I have the impression that the modal reader of the post will be below it.
2.1.1 supports the claim that making big life changes can be helpful for depressed people. It does not support the claim that mania/hypomania is innocuous. You might want to read about what it's like to be manic, because you seem to be seeing only the positive side of it (confidence, ambition) without noticing the possible psychosis, violence, anger, agitation, and deeply destructive choices that *can* come with mania.
I'm talking specifically of hypomania, not mania. At least by its modern definition (DSM-5 according to WP), it is a pure mood state, with no psychotic symptoms attached to it; one retains full awareness of what is happening and full control of what one is doing. If this is the worst that can happen from overcorrecting a depressive phase, I'd say it's a good deal.
Of course, there is a legit question underneath here, which is whether mania and hypomania are typically caused by different underlying factors, or differ only in the strength of the condition. My impression is that it's the former -- I would be surprised if hallucinations just emerged out of sufficiently high euphoria -- but this is for psychologists to answer. But I for one would happily trade a mild depressive episode for a hypomanic one.
Beyond the potential negative consequences of actions taken while hypomanic, I think the typical model is that hypomania does permanent accumulating neurological damage. [It might be fine this time, but that makes it worse next time, and so on.]
>German studies tend to do the best and American studies the worst, which might either reveal something about those countries’ cultural biases, or about the different strains and extracts of the plant used in the two countries.
I heard on a podcast that the difference is likely that St. Johns Wort supplements are regulated in Germany, and not so much in America. Which would mean German St. Johns Wort supplements are much less likely to be adulterated.
I don’t know any German St. John’s Wort but I’ve been talking the herb every day for three years since the Paxil I was talking started affecting my thyroid and I would include a warning about cheap extracts. They have no effect in my experience.
pretty sure you can order anything from amazon germany and get it delivered to almost any place in the world, including the united states :-) Regarding a "GOOD St John's Wort extract" .. never took it, so no experience with it. If you want to check for yourself, here it's called "Johanniskraut" or "Echtes Johanniskraut", you might want to look for a "Bio" label, that's similar to what you guys over there call "organic", unaltered, no pesticides etc.
from a quick glance i would say these look trustworthy:
Gaia herbs has an “emotional balance” formula with St. John’s wort in it. Seems to help in one kid but the pills taste herbal and so he takes 1 where 3 would probably help more.
German here. what regulations exactly did they talk about? I don't know of any, its considered a "normal" supplement here, you can order the dried herbs for tea or the extract, extract is typically in the 2000-4000mg range
Well, as I understand it, in 1984 St. Johns Wort was approved as a treatment for depression by Germany's Commission E. Which means doctors can prescribe it and as far as I can tell makes prescribed St. Johns Wort fall under the normal German drug regulatory rules.
In contrast, the Food and Drug Administration has not approved St. John's Wort as a treatment for anything, and it is classified as a dietary supplement, not a drug. Which means producers of St. Johns Wort in America fall under fairly lax regulation and enforcement as far as purity goes.
i checked it, you're *somewhat* right: there are a few products that fall under the described regulations, but the majority is freely available. the categorization is bizarre if you ask me, it is not the amount of St. John's wort extract contained in the drug or its effect or something similar that is important, but only the declaration of the intended use. That is, products intended for the treatment of severe depression are medications and therefore require a prescription, while products for mild and moderate depression are considered dietary supplements and therefore freely available on the market.
I guess the real question is which kind of St. John's wort did they use in the studies that found it was effective? I would assume the prescription stuff, but that's only an assumption.
However, on first reading the beginning section - "The short version" - read really oddly to me. It seemed peremptory, confusing, and almost flippant. I may not have any idea if I'm depressed or not, and suddenly I'm being told to consider a Mediterranean diet, methylfolate AND electroconvulsive therapy! However, once I had read the whole text, I reread this section, and this time it seemed fine. So IDK... but maybe consider expanding it a little and clarifying to the reader what the section is.
The "What is Depression" segment perhaps assumes a bit too much knowledge in the reader. I was trying to put myself in the shoes of someone who feels depressed but doesn't know much about depression, and I wondered if such a person would necessarily follow the use of quotation marks as a compressed way of referencing a whole complex area of what constitutes a real symptom, what psychosomatic means etc. I would consider laying out the issue briefly but explicitly rather than in this more coded form.
With your use of humour, I felt that at moments you were a shade too close to your blog style. In particular "being a moron", and "because the researchers were cowards", plus maybe the hole in the skull bit. I found these funny, as usual, but I wondered whether someone in a vulnerable state might find their trust in your otherwise very steady and reassuring voice undermined a touch.
The writing is refreshingly free of jargon. Exceptions were "modality" and "high withdrawal potential", the second of which I took to mean that it had danger of withdrawal symptoms, but I wasn't certain.
This sentence -
Some people act like the episode “continues under the surface” even when a medication is treating it, and if you restart earlier than this, it will show up again.
- for some reason I found it hard to follow and had to read it three times. I can't find any syntactic or stylistic reason why this should be so, so it's probably me. Maybe I'm depressed?
In the passage about the mathematical explanation, maybe you should link to your attractor posts? For someone without much maths it would be hard to get a sense of what the passage means.
Finally - and this is something you know approximately a million times more than me about, so apologies for the presumption... but I wondered if there should be more in the way of caveats? Particularly when it comes to medication, you say "You should consult with your doctor" but don't really stress that they shouldn't start necking escitalopram-ketamine-and-St-John's-Wort cocktails without seeking more advice first. I worried that someone like my cousin, who is not always depressed, but is always a total maniac, might just immediately get on the dark web and buy the whole list.
> Some people act like the episode “continues under the surface” even when a medication is treating it, and if you restart earlier than this, it will show up again.
I was a bit confused by it, too. Perhaps "act" is a bit ambiguous here (at first I understood it in the "pretend" sense).
I agree with this feedback 100% - I'd start with the short version with a very short and practical definition of depression, how you know you have it, then go to how to treat it.
> Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
This entire paragraph is very hard to parse for the non-mathematically inclined. I'd suggest either toning down the jargon or linking the hell out of it so that readers who don't understand the technical terms can go read a writeup of how that math works.
Additionally, the diet stuff looks *awesome* but there's enough to that section that you may want to make it its own page. Note how you went into a 4th level of numbering--typically that's a good sign that you've gotten technical enough that it should be its own page that you link to on the main page.
Although I understand the basic idea of the dynamic system paragraph, having read the explanation at https://lorienpsych.com/2020/11/11/ontology-of-psychiatric-conditions-dynamic-systems/ , I agree that it is probably more technical than it needs to be. I still don't know what "weights of the edges of the graph" is supposed to mean (I'm picturing a dynamic system as a curve on a multidimensional Cartesian graph, but I can't tell what would be meant by the "edges" of such a graph), & since this doesn't go into the math in any detail I'm not sure that it wouldn't be better to just write it less technically as something like "Depression can be understood as a set of several sorts of life events & biochemical factors which tend to occur together & reinforce each other, so that the overall state of depression is difficult to change & various subsets of these factors can, by bringing about related factors, shift a person into depression."
Thank you for the link because this is fascinating.
I did want to recommend rewriting the paragraph completely to remove all mention of this mathematical model as well, but I came to the conclusion after the diet section that this would be counter to Scott's purpose of offering as much information in as many formats as possible.
This much information may cause overload for the casual reader, however, so it may just be enough to provide the link you did and say "if highly technical mathematical things make a lot of sense to you, check out this model of depression."
Calling this a "graph" is normal in mathematics and computer science, but for the layperson "network" is probably a much clearer term.
In this context, "edges" are connections between nodes in the network, and the "weight" of an edge is a number associated with it, indicating how "strong" the connection is, in some relevant sense depending on the specific problem.
I already wrote it above, but IMO the issue is not that graph theoretic concept of graph might be unfamiliar to the reader, but the graph itself is simply not defined. What are the nodes of the graph? The text here does not say. How the graph is related to any dynamic model? The text, as is, does not say. My recommendation would be to define what the concepts refer to.
As a plus, the non-mathematical use of the word "dynamic" is a swamp of dynamic business jargon, it would help to be precise.
Really like the doc! It's really valuable putting all your expertise into these articles & think it will eventually be the Paul's Notes of Psychiatry.
I don't think this paragraph adds anything for the vast majority of people reading it and it just kind of hangs there without being connected to anything else:
> Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
Lots of people are a bit scared of mathematics, and this para doesn't really add a lot for the average reader - and it may be just one step too far into the technicalities for many.
Maybe would make more sense if he links it to his ACT article on this (or, since I imagine he wants to keep these separate: copy over that blog post into Lorien?)
Maybe I've read too many oversimplified depression guides, but I find this level of complexity to be refreshing. I think it could even be *more* technical, to be honest. I don't imagine Scott's strength is in writing "a good article for 95% of people" but rather "a great article for 30% of people."
Other material I've read makes a hard distinction between mild-to-moderate depression and severe depression, with the later being more amenable to treatment. No?
I think rhodiola extract helps. Worth researching?
I've found that the best thing for self-hatred, though not a complete solution, is to identify with the self being attacked rather than the attacking voice. Saying to myself that the attacking voice is factually wrong wasn't especially helpful. It's more feasible now that I'm less identified with the attacking voice, but it wasn't a place I could start.
One of the nasty things about diet is that the taste of sugar cuts through the depressive haze better than most things. I don't know whether there's a general solution for that. Fortunately, I'm able to take it seriously that too much simple carbs makes me feel bad.
Loved it and more helpful than anything I've read since coming to understand this was a trait in my wife's family... nit: 'pasttimes' not a word, s/b 'pastimes'.
You briefly mention wake therapy, but you do not mention the symptoms that suggest it might work, as described in your post https://astralcodexten.substack.com/p/sleep-is-the-mate-of-death . Is the omission deliberate? I'm one of those people who feel terrible in the morning, better as the day progresses, and good enough in the evening that I try to delay going to sleep. That post made me seriously consider the possibility that I might be depressed.
Good overview. Though I'd say my major depression comes from hopelessness, feeling disconnected. So there's a lot of existential pieces to it. Also, dunno about saying therapy from a book is just as effective. Sort of discounting the role of interpersonal psychotherapy in untangling and adjusting core beliefs through a real relationship, which can then translate to real world. Thanks for the read.
I liked this a lot! I would increase the emphasis on the fact that major depressive episodes tend to ease up on their own after 6 months. You note this in passing at the end in the context of medication but I found this knowledge super helpful when a doctor mentioned it while I was depressed (and, anecdotally, other depressed people I've known seemed surprised when I mentioned this to them). It helped me reframe depression from something I was failing to fix and made me see it more as something washing over me I just had to survive.
As you say, it feels terrible to be depressed and keep getting advice on how to be less depressed that you know you won't have the willpower to execute. (And if you think you'll feel this way forever unless you miraculously get your act together, suicidal ideations feel much more tempting.) In my case, just telling myself that waiting out the clock was also an option and I probably wouldn't feel this way forever even if I never managed to get on the right meds helped me about as much as anything else I did in terms of breaking the depression spiral.
Broad note: this feels less approachable than your average article, which seems unfortunate in something that depressed people are presumably going to be trying to read. I wonder if there's some way to organize each FAQ item so that it starts with an engaging claim or anecdote, continues with concrete recommendations, and only then goes into the justifications?
> Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out.
This is not my experience at *all.* IME depression is a lot like being abused -- no matter how bad yours is, you probably don't think you're *really* depressed.
> The most common are depressing jobs, depressing relationships, and (surprisingly often) depressing grad school programs.
Presumably massive sampling bias, but the two I see most often are "depressed from living with abusive family" (but convinced that their family is lovely; depression fixed when they move out) and "depressed from dysphoria" (but convinced they're cis; depression fixed when they transition).
> What’s the role of sunlight in treating depression?
I'm perpetually confused about what tradeoffs I should be making on this, as someone depressive who's also very pale with a family history of skin cancer. Should I be covering up on sunny days or taking my shirt off? Do I still get the depression-related benefits if I'm slathered in sunscreen?
> They come from normal healthy eating. Less processed food, junk food, and soda; more whole foods, nutritious foods, vegetables, and water.
I've always figured there's a Maslow's Hierarchy sort of thing going on here, where the base of the pyramid is *actually eating food.* I know a lot of depressed people who struggle to reliably eat *at all*; I wonder if it's worth actively recommending processed junk food in the cases where that might make it easier to get calories in your body while depressed.
Finally, some questions I hear a lot from depressed people which aren't addressed here (I'm sure you've already thought about many of these and decided against including them, but just in case):
- But what if antidepressants turn me into a drugged-up artificially happy zombie who can't feel sad about genuinely sad things?
- If I talk to a therapist about my depression, won't I get committed to a mental institution?
- What if I'm just a genuinely evil person who really should feel bad, and treatment makes me stop feeling bad?
- How can I tell if I'm depressed, or just right that the world is a terrible place hurtling towards destruction and ruled by people who torture babies?
- I've been on medication for my depression for ten years, and as long as I'm on it I'm good, and every time I go off it I become suicidal. But I'm good right now, so probably I was never depressed and this medication isn't doing anything, so it's a great idea to stop taking it, right?
(Okay, no one actually asks that last one. But it sure does come up a lot.)
Not sure what you mean by genuine issue. It is genuine in that many depressed people feel that way. It is a symptom of depression.
Sometimes we may feel guilt or remorse about a specific harm we caused and that feeling may guide us to make amends and change our behavior. That's the extent of the social value of guilt.
Marinating in feeling bad about oneself generally across days, weeks, and months is a symptom of depression and serves no use to anyone. It is part of the distortion field of depression and is harmful. Believing that feeling terrible about oneself is justified is a sticky way that the ego becomes identified with the symptoms of depression.
Anxious people do this too by believing that their constant worrying is helping to keep them safe in the world or is helping them become better people. These are delusions/symptoms of the problem that become clear once a person is more free from the grips of the anxiety or depression.
> This is not my experience at *all.* IME depression is a lot like being abused -- no matter how bad yours is, you probably don't think you're *really* depressed.
Seconded. I've had moderate symptoms all my life but didn't acknowledge it until midtwenties. How your environment-culture frames a) your behavior b) depression matters a lot.
> "depressed from living with abusive family" (but convinced that their family is lovely; depression fixed when they move out)
> Do I still get the depression-related benefits if I'm slathered in sunscreen?
I conjecture yes, because getting outside helps all on its own.
> I wonder if it's worth actively recommending processed junk food in the cases where that might make it easier to get calories in your body while depressed.
I speculate "no". In fact, I speculate that fasting might be better than eating terrible junk food. Sugar gives you a temporary dopamine hit, but then you crash when your insulin spikes, which drops your mood further.
Fasting reduces inflammatory markers, which have been implicated in depression, and your body releases cortisol to mobilize stored energy which manifests as more mental energy and clarity.
Furthermore, making a conscious decision to fast gives a semblance of control which can be a little positive victory. Then again, perhaps this should only be done if implemented as a conscious eating regimen where you force yourself to eat proper food when you should not be fasting.
That said, this is all speculative. Consciously implementing and adhering to a fasting regimen has helped me at times, but I doubt I suffer from major depression, so take with a shovel of salt.
I really enjoyed the dynamical systems post, but I think without the massive amount of context that it provides, its inclusion in the short version is confusing.
> Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out. On the other hand, if you really like going through checklists to figure out if you’re depressed, you can take the HAM-D, a very official depression test used in studies, and it will tell you exactly how depressed you are.
In my experience, chronically depressed people often assume that they feel the way everyone else feels and are just less virtuous and able to deal with normal life stressors. I've encouraged people I know to take the Beck Depression Inventory and they've found it very helpful with realizing that their situation is abnormal.
It might be worth mentioning eating disorders in the section on the Mediterranean diet, because lots of depressed people have EDs. Anecdotally, a lot of depressed people I know undereat, and getting enough calories tends to improve their mood.
Oh thank you for highlighting that -- I meant to say something like this but you said better than I would: "depressed people often assume that they feel the way everyone else feels and are just less virtuous and able to deal with normal life stressors."
For those who haven't had depression before, there's a boiling frog dynamic that makes it very hard for the person to identify when it's slipped from "going through a rough patch" to "this horror is my new normal and it's not normal and I need help."
The "what the hell is my problem?!?" voice is a big one keeping people from getting help.
It's definitely not my experience that most people know if they're depressed. Often people close to the person will know before the person themselves knows.
Also, reminds me to say: depression for some people mainly presents as heightened irritability. This is true of kids but is also true of some adults. I think maybe helpful to say that somewhere.
I live with someone with hereditary treatment-resistant depression that requires a continually evolving cocktail of pharmacologic therapies. She even went as far as ECT during a particularly acute phase of her depression before we found a new cocktail that has put her depression back in remission (for now).
Given this experience, I am likely biased in how I think about depression. And, with this bias, I found the Short Version a bit...glib? It certainly would turn her off if she were reading the short version. The long version I feel gets the balance far more right, but she might never get to the long version due to the short version's feel. Just something to think about if you're looking to attract and educate people who *are* depressed.
Other thoughts:
Before she did her first ECT treatment, I read up on what it does and how it works intensely, because I was scared of this procedure too. What I picked up was that ECT actually shuts down hyper-active neuron activity, and this made sense to me (but flies in the face of what you state in your long description).
It does appear to me that, when depressed, the patient is unable to turn off the "bad news feed" - and this appears to resemble over-processing, not under-processing, of information.
Further, it seems like a depressed person resembles an incredibly self-centered person as well - a negative narcissist, if you will. The pain they are in makes their entire existence about *them* at all times, which is probably not normal or healthy. Further, I completely agree with the intersectionality of depression and anxiety, but I would like to suggest that sensitivity be added in here as well.
When she is depressed, I witness someone who is hyper-sensitive to stimuli, hyper-aware of self (in a negative context), and constantly swirling in a heated stew of brain pain. It's a vicious cycle. An analogy I use to describe what I witness is that while I go through life in a car with shock absorbers, she's going through life dragging her knees on the pavement. She's just so much close to the ground, with no ability to modulate or buffer the inputs.
And it's this inability to modulate or buffer the incoming data that leads me to the hypothesis that depression is actually about hyper-active neuron activity vs. too little.
Strong agreement with the 'negative narcissism' sentiment. At my most miserable, I was more or less incapable of taking other people's needs or desires into account – I was too preoccupied with plugging the gaping wound in my own brain. I went into this in more detail in my own comment, but volunteering at a local homeless shelter was, for me, a more effective treatment than any SSRI.
Obviously, unless your social group is willing to give you a lot of slack, this can feed into a deeply tricky cycle of isolation.
Thanks for sharing. It does make you wonder if there's another angle of depression treatment which is more about forcing external stimuli that demands reaction from the depressed subject.
It also makes you wonder about why crippling depression exists evolutionarily... why does it persist? What we perceive as depression is actually more of a misalignment of actions and purpose that, to your point, can be addressed by changing the stimuli? I do not mean to sound glib; I recognize that nothing is just that simple. But I've never heard of depression spoken about before through the lens of narcissism or self-centeredness. Worth exploring?
I've encountered a few attempts at evolutionary explanation, but none of them were exactly elegant. The best one argued that it was a sort of risk-minimizing hibernation; if the world is (or seems) randomly harsh, if effort seems uncoupled from reward, then it makes sense to sleep a lot, not attempt new things, and eat calorie-dense food. That may be part of it, but I tend to think there's much more going on here, and some of it may not be even vaguely adaptive.
"In this randomized clinical trial of 24 participants with major depressive disorder, participants who received immediate psilocybin-assisted therapy compared with delayed treatment showed improvement in blinded clinician rater–assessed depression severity and in self-reported secondary outcomes through the 1-month follow-up."
It does sound promising, but the facts that 1) it's one very recent study, with 2) a sample size of 24, and 3) only *one month* follow up give me some pause. Is anyone aware of other research on psilocybin for depression? Is there any reason to believe that this apparent ameliorative effect for one month would continue (or not)?
The paragraph beginning “In a study in India” has a duplicated comma and what feels like too long of a link to me? It’s hard to distinguish that link with the subsequent link to an iron supplement - I would make the link attach only to the word “study” at the beginning.
Unrelated, but I also wonder if more pictures in this writeup would be advantageous - you're optimizing for readability within a population not known for its dedication to reading thousands of words of technical information, and while it's more readable than anything *else* I've seen on depression, I don't think it would hurt to push a little harder on the "low effort to read through" side of things.
The thing with images is that they only help if you use them to illustrate the idea or showcase something.
It's easy to insert random vaguely related pictures you've found on google into any text, but that's rarely a good thing to do.
I think Scott is right in avoiding illustrations here, because it's hard to add any meaningful images when the topic is so abstract, and you don't want to dilute the message with random noise (irrelevant pictures). Which might be even more relevant if we talk about people with decreased attention.
This paragraph was the first paragraph I could not easily understand.
Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
I don’t know what an attractor state is, and how it relates to “weights of the edges of the graph.” You may want to translate this paragraph into layman’s terms.
Some random comments below. Overall, shorter paragraphs would be good. Walls of text are hard for someone who is depressed. Seems like this may be trying to do too many things at once -- I wonder if a more spare structure with links to side subjects might be better. The level of generality varies a lot which makes it a bit unclear to me who you see the main target audience to be. It's clearly more than just potential patients, but for people beyond potential patients, it seems maybe too specific about dosages and supplements/meds in a way that strikes me as risky.
Some of the details are lovely -- like the Levitt study.
Okay, some specific points, take or leave, for what they're worth:
* Section 2, para 2 "so nobody should feel obligated to try any modality that doesn’t feel like a good fit for them" -- I think reluctance to try things is a big barrier to treatment. People are terrified that something new will make them feel worse and that they can't risk that. So I think people ought to be encouraged to TRY things and that only by trying things will they learn what might be a good fit. There are so many people out there who say "Oh I hate antidepressants" who have never taken them or "I know therapy won't work for me" who have never tried. We are incredibly wrong sometimes about what we think we know and are so good at making excuses when we're afraid. We want to encourage people to take some risks in order to get treatment while their depression is likely to make them extremely, paralytically risk-averse.
* Stress isn't mentioned anywhere in here that I saw. Stress is sometimes a really big factor in depression. You mention situational things like bad jobs or relationships. It might be good to mention that long stretches of elevated stress can produce depression as a result, and that stress-reduction may be an important part of treating depression for some people.
* Women and hormones. I had two cases just this week of women who were on different forms of hormonal birth control who upon discontinuing (or changing) saw all their depressive symptoms resolve after years of suffering needlessly -- these stories are widespread. Hormones mediate mood for women a great deal. I know for men as well, though differently. Worth a shout-out somewhere. You could include where you mention thyroid and anemia or separate para. Research I saw said HRT is more effective for depression in perimenopausal women than any kind of antidepressant -- and yet doctors are still not acting like that's the case. Women are perimenopausal for like a decade of their lives and are routinely put on SSRIs during that time for mood issues. And side note: I still meet psychiatrists who don't realize that you can treat PMDD by doing SSRIs for last part of cycle only.
* Lots of depressed people I've known/worked with were surprised how much their physical pain turned out to be part of their depression. Some mention of that might be helpful. You mention in passing re: Duloxetine, but might be good to say somewhere up top related to symptoms of depression itself.
* I know a number of psychiatrists and psychotherapists using psilocybin-assisted psychotherapy. Is it right to just say that psilocybin is illegal?
* I've recommended L-methylfolate to a ton of people and many people have reported benefit well below 7-15 mg. It seems a bit definite to me to recommend the max dose if you're going to be mentioning specific dosages in here at all. I encourage people to find min. effective dose in everything because people metabolize all these somewhat differently. You could cut part about MTHFR because people who don't know about it won't care and people who do won't gain anything from your mentioning it (I would edit out mention of more things like this in there, not central to what you need to convey). I agree it doesn't need to be factored in.
* Do you think it's worth mentioning neurofeedback? Defer to your research. Have seen some good results for depression (and trauma and anxiety and insomnia).
* Surprised you recommend Wellbutrin as the first-line since anxiety is so often also an issue and people may respond badly. OTOH, I like that you do because it's under-recommended. But then this raises for me why you want to lay out these specific regimens anyway -- if readers are going to be your patients, they're going to get your best judgment for their situation. If they're going somewhere else for a prescription, they're not going to get Wellbutrin because they read about it on your website. I think you could make the regimens more general and thus simpler.
* None of the regimens say "see a therapist." Which seems inconsistent after pointing out that combo meds AND therapy are the most effective.
* There seems to be some equivocation between 5-HTP and SAM-e and then you end up recommending 5-HTP mainly. Not sure the logic there. I've had equally mixed and good experience from people with both. 5-HTP game changer for some, totally ineffective for others, and made some people VERY anxious. SAM-e seems to produce less love/hate reactions in my experience. Don't see a reason to recommend one over another, but your experience may say different. All the supplements are a bit of a black hole unless you want to address in a separate article. The only one I feel like is a no-brainer for people to try is L-methylfolate.
* I guess I take issue with recommending behavioral activation above all other forms of psychotherapy. Many psychiatrists say to their patients, "if you're going to go see a therapist, at least make sure they do CBT." That one doesn't offend me quite as much as a narrow focus on behavioral activation. It's also going to be harder for people to find a therapist by saying "I want someone who will do behavioral activation." There's decent research that the outcomes for intensive short-term dynamic psychotherapy were more durable and just as effective as CBT. People with long-standing, recurring depression are going to need something more comprehensive than behavioral activation. In any case, I don't see a reason to single that modality out from the point of view of the person seeking therapy particularly when we don't know what's going on with that reader's particular depression.
Addendum to the comment on women and hormones - I have noticed that HRT, and specifically oestrogen supplementation, has been the salvation of several middle aged women in my social group. It seems to have a powerful effect on both long-term mood and physical function.
I'm surprised by the advice not to listen to "sad music" when depressed. Does the psychiatric community not view catharsis as legitimate or useful? When I'm down I'm going to be more in the mood for Leonard Cohen or the blues or Schoenberg. It seems to make me feel better. A sign that I'm really down is when I'm not in the mood for music at all. That's more like staying in the dark bedroom. Good, "sad" music seems to work a lot like hearing a good cynical joke. Perhaps it's a "misery loves company" effect. Music that fits your mood can be good company.
Or perhaps it is analogous to what you say about exercise: perhaps it would be better to listen to more energetic, "happy" music if you can stand it, but that's more like a vigorous workout, whereas listening to "sad" music can be more like a walk that at least gets you outside.
Disclaimer: Pro: I'm a Psychiatry resident. Con: I'm a psychiatry Resident
I feel this guide (and modern psychiatry for that matter) does a major disservice by grouping all of depression into 1 category. In the beginning, you mention it has biological, psychological, and social causes... but you don't mention that there's biological depression, psychological depression, etc... and that these are completely different entities with completely different treatment modalities. I think you can still leave everything grouped, but consider giving more credence in the beginning to the fact that a 50-year-old man with catatonic depression has a categorically different disease from the "really depressed" 16-year-old girl who "just can't" while sipping on her mocha latte.
Also... I would consider removing from "The short version" recommending reading David Burns' book (or any book for that matter, especially one you haven't read). I personally think it severely minimizes how complicated the psychological cause is for psychiatry. I'm one of those weirdos who likes psychoanalytics, and think Depressive personality disorder should be more widely recognized. The thought of someone with a personality disorder reading a book with the intention of fixing their "psychological depression" makes me hurt inside.
I agree about not recommending Burns' book specifically. I've recommended that book among other to lots of people and have gotten better feedback from things that are either more workbook-y (like DBT or ACT workbooks that have lots of exercises) or things that are more compassion-based (like Kristen Neff et al).
That link to the fugitive psychiatrist is a good one, thanks. I liked the whole description of "the hill" and that everybody has a hill.
I also liked this: "Psychotherapy also has the added benefit of providing long-term relapse prevention (1). You could attempt to prevent relapse by cycling though antidepressants for the rest of your life, but after your second go at paroxetine you’ll see why this isn’t the best strategy."
Even if lifestyle and cognitive habit changes alone don't get someone out of a major depressive episode (sometimes they do, not always), they are often an important part of preventing relapse back into one.
In section 2.1, you might consider that "getting away from the depressing thing" is only useful advice if a person is depressed by outside circumstances. (Or has the financial wherewithal to change their current work/life situation.) People suffering from depression brought on by internal things like PTSD, body dysmorphia, or internalized self-worth issues are more likely to see themselves as the problem. And if you are the problem then the fastest, most effective, and permanent route to "get away" is suicide.
Obviously, that's not what you're suggesting, but it is the worst possible way that section could be read. And your target audience is primed to read things in the worst possible way.
This is a good rough draft, but the people you want to help are going to have a lot of heavy triggers and you should consider having someone read it through for those.
As an anxious person who cooks a lot, I have always found injunctions against "processed food" deeply panic-inducing because I have no idea which of the things I do in my kitchen are "processing" and the underlying studies tend to be based on unhelpful or weirdly demanding (eg, Siga says that flour is an "unprocessed" food, baked bread is "processed", and sliced bread is "ultraprocessed"; who knew my hands and knife were so powerful!) or inconsistent (NOVA says "extrusion" is ultraprocessing, but pasta "unprocessed" despite being made by extrusion?) and seem to assume that nobody ever prepares their own food.
And that's without even starting on fermentation.
So if you are going to ask an anxious person to avoid processed food, please do them the service of telling them what "processing" is in the context that you intend, or check that the studies you are relying on use the same definition of process and of UPF. There is after all no need to drive us any crazier than we already are.
As a nonanxious person, i generally interpret "processed" as anything that you dont cook yourself. Companies that perform complicated recipes in factory, like bread or cake or processed tend to put in lots of obscure chemicals, maybe a color or flavor enhancer, anti spoiling agents, something for flavor or smell. Many of these chemicals have unknown (possibly no) effects on human health. Raw products like flour, fruits and veggies, etc tend to have fewer such alterations. So theyre "unprocessed".
Yes, I would take the stuff about bread to mean that if you *buy* a pre-made loaf of bread, that's processed, and if you *buy* pre-sliced bread in a plastic bag from the supermarket, that's ultra-processed (because it usually contains a lot of additives which are needed to keep it fresh when it's already sliced and has a lot of cut surface area). If you bake bread at home and then slice it, that's unprocessed. I'm sure they're not expecting anyone to eat raw flour.
But I agree the terminology is confusing, and it would be helpful for Scott to clarify briefly when he refers to it.
(Similar issue with "fried food". I assume it means fries from McDonald's or deep-fried battered fish from the chippy - not fresh vegetables and salmon that I shallow-fry myself in a little bit of olive oil or coconut oil. But the terminology is confusing.)
I also got really concerned about "fried." If I broil a burger it's okay, but if I finish it off in the cast-iron, it's bad?
And a limit of "three per week" for processed foods could be an impossible task for lots of people. I almost got anxious thinking that I might be hitting that right now, with an overall healthy diet full of vegetables and things that I cook myself. People who don't have the skills or tools to cook meals for themselves need some firmer/easier [1] guidance.
"Replace soda with water," on the other hand, is a feat anyone can do.
[1] Yes, that sounds like a contradiction. But by "firmer" I mean "more concrete steps for how to remove more of these things from your diet." By "easier" I mean "things that can be accomplished."
"I also got really concerned about "fried." If I broil a burger it's okay, but if I finish it off in the cast-iron, it's bad?"
I think the question with fried food is things like "do you use a lot of oil/animal fats when cooking, are you cooking very fatty foods, are you deep-frying a lot of foods?"
If you're cooking burgers, depends how fat the mince meat is, generally I find there's enough fat in the meat naturally not to need more added when shallow frying. If a lot of fat runs off as I'm frying, I'll either spoon that out of the pan and dispose of it, or (for example) remove the sausages etc. and dry them on kitchen paper while I fry eggs in the fat.
"Not too much fried food, the food not with a lot of fat in it before frying, cut down on the added fat as much as possible" is the reasonable way to approach it. If you're roasting meat, you need and want a level of fat in/on the meat so that it won't dry out while cooking. If frying, you don't need as much fat. If the meat or fish is very lean, use a little bit of vegetable oil to cook it.
I think a lot of the difficulty is around "process" being a verb but the actual plausible subject of most of the studies being nouns -- ingredients in the food -- rather than the actual, er, process of making it.
It seems like the word "processed" some times means a list of ingredients rather than any particular act of processing -- or even some times an attempt to not actually just list the ingredients, so as to keep me guessing (is my pickling salt evil? yeast extract?).
Which means when I'm feeling tired, sad, and unmotivated to cook, there's yet another voice in the kitchen telling me I'm not worthy of cooking because the hand blender is going to give my family processed cancer. Because anxiety brain is a cruel evil liar.
That is just way too extreme, IMO. You can get lots of fresh bread from bakeries, and even from Ralph's (or equivalent), without any kind of preservation agents. Yes, if you buy pre-sliced bread in a plastic bag, it likely won't taste nearly as good, but no one is forcing you to do that (other than lack of funds, admittedly).
That said, someone does expect you to eat raw flour, or something close to it :-)
It's hard to do because it's not cut and dry, but the meaning is still there. In general, when factories "process" things, they tend to make the thing more consumable and you eat more of it. Slicing bread makes it more consumable, and, presumably, you may consume more of it.
Because the bread was processed to make it more consumable, in the steps of processing, they could have added other things, that also make it more consumable. Sugar. Preservatives.
In general, (and this is a broad rule of thumb) the more processed the ingredients are before you touch them, the unhealthier the food is, and the more likely you are to overeat.
It makes sense, if you think about it. Companies are incentivized to make things as consumable as possible. Unhealthy food is often more consumable. That's why things in America are considered both very commercialized, and very sugary/delicious/obesity inducing.
So, we don't need to know the EXACT reason why, but when comparing two foods, let's say, guacamole pre-made in single size containers, guacomole pre-made in a large container, and a guacamole kit that comes with 3 ingredients, and an avacado, they go from most processed to least processed. It's possible the ingredients and nutrition and portions COULD be the same in each step, but just the matter of portioning, or what ingredients you choose, or a bevy of other hidden things (salt added, preservatives, enriching, etc) make it not that processed diet.
By trying to eat how Scott is suggesting, I'd recommend trying to start from base ingredients more often. It will feel healthier in a lot of ways. At least begin by starting less processed. Maybe you don't make your own naan, but you make your own hummus. Maybe you stop buying premade salads and start buying heads of lettuce. etc.
Not something I had considered but you are correct, for anxious and/or scrupulous people this kind of blanket phrasing can be very confusing and worrying.
Okay, generally take it that by "processed food", what is meant is factory-made products high in sugars, salt, filler starches, and other bulking agents. Some may or may not have artificial flavouring, artificial colouring, artificial sweeteners.
Some processed foods will have a lot of fibre/roughage removed. This is where it gets tricky, because frozen vegetables? Nearly as good as buying raw, whole vegetables and much easier if someone is depressed and suffering from lack of energy/motivation, so that cooking with frozen veggies is easier than the task of buying, washing, peeling, chopping etc. whole vegetables. Processed peas in a tin packed with sugar and salt? Not so great. But again, if it's a choice between "peas from a tin" or "no vegetables", then half a loaf is better than no bread. Processed foods as in "ready-prepared carrots in a bag"? Great, they've only been washed and chopped so you don't have to do that.
Speaking of bread, yeah, carbs are The Devil (I am trying to diet, every diet recommends cutting out carbs, guess what I love - yes, bread and spuds). Processed bread = white bleached flour with improving agents and full of air. Not everybody is going to home bake their own bread, so while you needn't break the bank on buying artisan bread, try to go for wholemeal or breads that are fortified.
> As an anxious person who cooks a lot, I have always found injunctions against "processed food" deeply panic-inducing because I have no idea which of the things I do in my kitchen are "processing" and the underlying studies tend to be based on unhelpful or weirdly demanding
Good point. Clearly "unprocessed" foods are those that are or can be eaten in their raw form, like lettuce and fruit. Every other form of food is processed to some degree, so the question is only what the processing introduces or removes from your food.
Some foods can't be eaten or digested at all without processing, and processing makes their calories more accessible, like flour. The cooking process can also make food safe to eat. Clearly some processing is beneficial, because calories matter most of all to survival, but processing can also reduce the nutrient content of food. For instance, boiling or peeling can remove nutrients from vegetables that may be in the skin. Nutrients are less important than calories, but still important.
On more extreme ends of processing, are foods that are wholely synthesized, like candies and artificial flavourings. These are generally considered unhealthy because even if they contain calories, they rarely contain essential nutrients.
In this category are also foods that add ingredients so they taste better or addictive (to some people), like adding too much sugar or salt.
So processed food is not necessarily bad, just have it in moderation and preference less processed food, if you can afford it. If you're financially less well off, processed food can often get you more calories per dollar spent, but you might be short on nutrients.
Let's break it down to the specific things that food manufacturers do that make our food less healthy.
1. adding lots of high fructose corn syrup to everything: this adds nutritionless calories and makes you fat since you have to eat more food to get the same amount of micronutrients. Hunger is sometimes affected by micronutrient statuses, for obvious evolutionary reasons. HFCS also makes the food taste better, so you eat more of it.
2. adding nitrites to cold cuts: nitrite is a strong oxidizer. What could possibly go wrong? Studies have linked it to DNA damage and colon cancer. Beware celery concentrate is a synonym for nitrite.
3. Adding lots of high-PUFA vegetable oils to everything. Most people already consume too many omega-6 PUFAs. Plus PUFAs are unstable at high temperatures and not appropriate for frying or high-temperature baking. They turn into trans fats and other bad things. [all fast food joints fry with high-PUFA vegetable oils anyway because they're cheaper than coconut oil or tallow. Hence the ubiquitous advice to avoid all fried foods. But maybe it's not frying per se, but the breakdown of PUFAs at high temperatures. Tallow fries are tastier and healthier]
4. adding lots of preservatives to everything:
(speculation, not aware of any study testing this) excessive preservatives might kill some of your intestinal flora, leading to worse digestion and downstream effects on weight and immune function. McDonalds food always aggravated my IBD, and I blame it on that. It is probably better to eat food that has been preserved by freezing rather than food that has been preserved by biocidal chemicals.
I would not mention ECT in the first paragraph. It makes the topic seem scary, and ECT is rarely used anyways.
I think one of the main contributors to depression that is possible to solve but hard to solve, is an unhealthy living situation. Living with an abusive household member, working a dead-end job or a job you hate, living in an expensive area with no hope of upward mobility, living in a gloomy place if you have SAD. All of these contributors have a solution, but the solution requires a big change in the patient's life. Often treating the symptoms is all that can be done, but sometimes the cure is removing the big problem in your life. These solutions are more social work than psychiatry. Even if you are not equipped to help apply them you could assemble a roster of helpful resources for your patients.
Maybe your patient profile is more in line with the person who has a great life yet thinks they are a failure because of a biological condition. But many people are depressed because they have bad life situations. It would be a great thing to help even a few.
That statement was immediately followed by an explanation of this idea:
> A prior is like an assumption, bias, or context, in the sense “you have to take that in context”. Your brain is constantly applying priors to all its perceptions to try to wring as much extra meaning out of them as possible – you can see some examples here [link to summary of "Surfing Uncertainty"]. A global prior on negative stimuli means that the brain interprets everything it sees in the context of an assumption that it’s probably bad.
I would expect that readers who read the explanation, & perhaps read the linked article, would understand this idea.
> Most studies that found supplementation helped got effects only from very high doses (around 2 g daily), more than you could realistically get from capsules – so if you are supplementing for this purpose you should consider liquid oil.
I have 2000mg fish oil capsules right here (though admittedly they are quite big). Looking at the ingredients just now, I see, however, that it's only 700mg Omega-3 fatty acids and the rest is, I guess, other kinds of oils, so maybe I should buy other capsules.
I loved this article and very much wish it had existed when I was a depressed 19 year old so I could have read it then (I'm 34).
I don't have a critique of what is written, but I think there's a very very very important section you need to add. You talk in 2.6 (and mention earlier) that before treating depression one needs to figure out if he is bipolar, or if the depression is caused by insomnia, etc. This is all great and true, but would be VERY USEFUL which is not provided here or by any other depression resource I've seen is ***how to tell if you're depressed or ___________***. A thing that could go a long way here is some simple scripts for how to talk to a healthcare provider about these distinctions, in a way that is useful to the clinician.
When I've struggled with depression, one of my biggest hurdles has often been wondering, "am I actually depressed, or am I just an under-achieving fuckup who is looking for an excuse to rationalize my under-achieving?" Similarly, I have read lots and lots of things and am still not really sure if I'm just depressed or have anxiety or am bipolar or a regular insomniac or have circadian rhythm disorder or ADHD (I think ADHD needs to be brought up at SOME point in this post because the ADHD --> overwhelmed --> failure --> depression pipeline is common, but also lots of ppl think they have ADHD and don't).
For a personal example: in Jan/feb 2020 I couldn't sleep at all, sometimes staying up 60 hours in a row, in hindsight I was definitely hypomanic, but that is the only time I can remember being any degree of manic. Am I bipolar? Or did I just have a million stressors (new job/new city/breakup/chronic back and stomach pain that was aggravated by the stress) and how should I know? What's the most productive way to talk to a clinician about it, because even though it's totally irrational, I'm convinced a doctor won't believe I have real problems because objectively I shouldn't so I must be faking?
Even within the classic symptoms if depression list it's like:
1a/b) is my low mood because of depression or because fucking Donald Trump is president and everyone seems to be in a low mood? Am I anhedonic or is there just nothing to feel good about, like objectively?
2) I have always had trouble getting to sleep, but I don't think I've always been depressed? Am I "depressed" because I'm not sleeping extra badly right now because of a constellation of outside forces or because I actually suffer from depression? How would I know?
3) loss of interest in activities: well I've never really been one for hobbies, and my interest in video games/reading books/watching tv/scrolling Twitter has always waxed and waned. Am I losing interest in activities, or have I just not found the right game/book/show/etc
4) Guilt: how do I know when I'm feeling a correct amount of guilt vs a depression amount? I try to be a decent person, but there are times I have treated people I care about poorly that I'm right to feel guilty about, how do I know if it's a symptom of depression or a functional moral compass? Everybody gets random memories of times they were embarrassed as youngsters and we talk about that as a cultural phenomenon, but other people get that about guilt, right? It's not just me, right?
5) lack of energy: is it because I've been having trouble sleeping or because of depression? Is it because I'm in my 30's now and I just have less energy, it l or depression? Is it because my job is demanding or is it depression? You know? Am I just whining about things everyone feels, or am I uniquely tired in an important way?
6) Concentration problems. So this is a personal one for me. I was a classic, "gets almost all A's, 99th percentile on every standardized test I ever took, never does homework or studies, was fine graduating 9th in his class instead of first" type of under-achiever (I also went to a very poor public high school). I always wondered if I had ADHD because my best friend did, and it seemed like our brains worked the same, and when I'd read things by ADHD people about their disorder it felt familiar, and in college I used buddies in a frat to get black market adderall and I studied much better on that. BUT: maybe school is just boring and everyone functions better on stimulants? And I worried my doctor(s) would think I was just bullshitting to get access to Adderall if I brought it up.
7) appetite problems: so many things affect appetite, it feels hard to pin it to any particular source
8) <skipping>
9) suicidal thoughts: every millennial I know "jokes" about wanting to die, when I think that is it a sign of depression or just how my generation articulates stress?
Anyway, this comment has gone on long enough, I hope you find something useful in it
Addendum: I know it's a tricky legal area for you, but the fact that you don't address Marijuana as treatment for anxiety/depression (whether you think it's total bullshit or not) is probably the biggest hole in the piece
Here are some things i have experienced that in hindsight were for me indicators I was severely depressed that I think may be relatable to others:
1) feeling lonely, scrolling through my entire contacts list, and about every person thinking, "they don't want to hear from me, I'll just bum them out"
2) thinking about brushing my teeth for the first time in two days and then deciding, "fuck it, it doesn't matter"
3) spending every waking moment both playing a video game AND listening to a podcast or tv show I've seen before so I don't have to think about my life in any way whatsoever (note: this rationale was only clear in hindsight)
4) not drinking water (this one sounds stupid but when not-depressed I drink lots of water)
"2) thinking about brushing my teeth for the first time in two days and then deciding, "fuck it, it doesn't matter"
Yes! That is one of the strange things about it, the way it just leaches away energy and ability to do things. Objectively, you know you should brush your teeth, it'll only take a couple of minutes, what is the problem? But the very thought of standing at the sink and getting the toothpaste and - ugh, leave it, too much work.
Sitting in place for twenty minutes trying to persuade yourself to do some small necessary task that will only take a couple of minutes and being unable to get up and do it.
That's why the advice about "just get up! just go for a walk! just start eating healthy!" - you *know* it's good advice, you *know* it will help, but taking even one step? It's like asking you to fly to the Moon by flapping your arms.
I have no idea how much of this might apply to other people, but have a data point.
This is reminding me of the time I read Oliver Sacks' book about Parkinson's, and it seemed to me that my difficulty with taking action was like a mild version of what they had. (I didn't think I had Parkinson's.)
It seemed like the right course was to learn enough neurology so I could do something about it.
Weirdly, even though I couldn't get myself to study neurology and even though I thought there might be a physical basis, I became a lot harder on myself about having difficulty with taking action.
I told a friend about this, and she spent 15 minutes telling me I was a good person. No specifics, as I recall, just the generalization about being a good person.
The difficulty with taking action lifted for about two weeks.
No need to give more info here obviously, but I would be curious if you find it clarifying taking the HAM-D assessment Scott links to or you can also find a PHQ-9 free online and see how you score (https://patient.info/doctor/patient-health-questionnaire-phq-9).
These assessments aren't god or replacement for a good clinical interview, but they can cut through some of the circular questioning that people can find themselves in when they are depressed. If you take them across time over some weeks or months, you can also get a feel for your own ups and downs, and it can help provide a somewhat more objective perspective out of one's subjective experience.
One of the trickiest things about depression is that it does often manifest as a very loud inner critic who then tells us we're "just whining" or that we deserve to feel guilty or whatever. Depression creates a really big distortion field in our perceptions and thoughts that while isn't full-blown psychosis, is nonetheless very very hard to see outside of. From inside the depression, the volume of the inner critic doesn't seem like a manifestation of depression but rather The Truth about us or The Truth about the awfulness of the world. If we're pretty identified with that inner critic anyway, it's going to make it that much harder.
Right, so everything you said here is 100% correct, and thanks to some combination of SNRIs, lifestyle changes, and "who TF knows" I've been pretty okay since late 2020, I was just giving feedback on what I thought would have been most helpful for me (I am not representative of depressed people generally, obv) when I was very depressed/anxious and casting about the internet for ideas
Re; #3, apparently the cut-off for anemia is too low, currently. Most people who are in the 'low but still normal' range for iron experience significant symptoms, so could benefit from further inquiry into why their iron is low and/or supplementation.
I'm not trying to be snarky, this is a genuine question: Does that mean that a homophobic right-wing depressed patient should see a homophobic right-wing therapist?
I used "homophobic right-wing" because, by reversing the example used in a directory contrary to conventional morality, it reveals tensions between different criteria for a therapist. I can think of 4 criteria that might be in tension:
1. A therapist should ideally have the same worldview and moral beliefs as the patient.
2. A therapist should ideally have dealt with (or be dealing with) the same mental "disease" as the patient.
3. A therapist should have the conventional morality of the patient's culture, to help that patient better fit in and attain what's regarded as "wellness" by that culture.
4. A therapist should have an objectively healthy worldview and morality, and be free of any mental disease, in order to guide the patient in an objectively good direction.
To me, it seems like each of these are important. But they can directly conflict with each other; and each feels very wrong to me in some circumstances. The profession thinks it's addressed these issues, but maybe all it's done is privilege the dominant culture in the same way it did in the past. In the view from inside a culture, using only criterion #3 would feel like using all 4, because we choose examples which address the problems we ourselves perceive as most worthy of attention.
I agree with previous poster, the actual beliefs and attitudes of the therapist are less relevant than whether the patient FEELS understood and that the therapy approach suggested fits them well.
And sometimes 'personal chemistry' is mysterious - which just means too complex or non-obvious to easily figure out.
I've spent many years treating some patients whose politics/values were VERY different from mine, quite successfully. I'm sure that within a few months or a year they had figured out I was not a 'match' for them in that way. But we worked together with mutual respect, I helped them figure out how to live within THEIR values (and gently challenged a few things that seemed inconsistent value-wise while quite consistent 'tribally'), and all was well.
My experience is that, before 2016, shared beliefs and interests seemed to have little correlation with how well I got along with someone. Shared epistemology and curiosity might have correlated with that.
For the purposes of useful medical attention and the best chance of recovery, the answer may be a tentative yes.
Although it sounds a bit distasteful when you put it like that.
One way to look at it is that for the best chance of a medical professional and a patient being willing and able to work as a team, they need to have at least some underlying beliefs and values in common. Plus, the patient needs to be confident that they can be open and, yes, even vulnerable to the medical professional.
This is not as likely to happen if there are significant differences in their foundational beliefs. That's not to say that it can't happen; just that it is less likely.
The problem pyentropy mentioned above, about smart analytical children becoming severely disillusioned by their therapists is a real one (and it isn't confined to children, either).
I think sort of yes, but it's just a proxy. For this kind of therapy I think the real crux is whether the therapist "gets" the patient in a way that the patient feels "gotten," by which I mean the patient can (hopefully correctly) sense that the therapist understands their values and motivations and situation and is an ally in supporting them in a way that respects and accounts for them as a person, ie. on both a practical and identity level.
I think by default you get that kind of compatibility when you really do happen to share a worldview, but it's not a necessary condition: a skilled therapist can and will do all these things and cause the patient to correctly sense they can and will do all these things, even if the therapist is totally different from them.
Yes, of course.
Homophobic right wingers can be great therapists too, the last psychiatrist (see the blog) is a great example, and even Scott vouches for him as an inspiration in terms of pharmacology and Freudian psychotherapy.
Was TLP homophobic or all that far right? I remember some spicy takes on the transgendered (that stopped short of outright denunciation (and some crimes of writing style (such as these nested parentheses))) , but can't remember if he had anything negative to say about gay people.
If you really believe TLP was either homophobic or far right I'd like to just point out that he routinely switched implied genders and wrote contradictory personal anecdotes, specifically to keep people in the dark about his identity and personal beliefs.
Thanks for this post. As a patient in my 20s I found the psychiatrist uninterested in understanding and unable to know about what I wanted to get better *for*. Being frantic at a disconnection from one’s gift is sort of just more BS to some docs. I think Scott is an exception to this.
Later in life after getting bonked in the head I was taking some kind of “arrange the tiles” test. I got some but then screwed up. The examiner said, you did really well, as for the ones you missed, only engineers get those right. She smiled at me. I expect to remember that as long as I live!
High performance is sometimes thought of as some type of gravy on the meatloaf of life. I don’t really get there anymore but I remember when that WAS the meatloaf. You are right, child psychiatry is kind of a minefield. I hope we move toward a society with more awareness of subtle aspects of mental wellness. I think it’s easier to heal little problems before they get big, but they have to be noticed first.
You’re not wrong about getting sick/older, it does happen to people all the time. Change and loss are part of life, that’s true too. Good treatment is also hard to find. If you can access a doctor a good holistic practitioner might be a good direction. I may be done with talk therapy, I had EMDR for a few years about 15 years ago and it really helped, I got some function back, then I went and made more choices and blew even more. Went into a talk therapist’s office two years ago and left feeling undeserving. Later that day she sent me a text declining to work with me, haha. Not everything is addresssble in speech. I had two sessions of chakra clearing a decade ago that did more in a few hours than talking did in hundreds of hours. A few chi gung exercises really helped but I forgot a detail and can’t find the description. Also taking certain foods out of my diet (peanuts, some additives) lessened the internal stress; getting a CPAP for the sleep apnea helped clarity; thyroid supplement; treating the background ADD; beginning a recovery practice and submitting to an ever-evolving pile of pills and vitamins. Also learning to seal aura/close energy. If you ever decide to pursue healing modalities again there might be something out there that wouldn’t be a net negative for you. In my early 20s I let it ride but untended it got worse rather than stay steadily bad, so for me I have to be active. Close to 50 now and some doors are finally creaking open again.
If being intentional about healing creates a feeling of stripped gears or disempowerment, personally I take that as a sign to change the pills. “Effort makes it worse” is not too far from suicidality for me and I try to stay out of that zone. I never liked the diabetes metaphor of mental struggle, I prefer a “knee injury” model; I may need a brace for the rest of my life, or so to speak a mobility scooter, but I don’t have to give up going from place to place.
I’ve seen people feel like hell from undiagnosed Lyme disease or Epstein-Barr virus and feel better with treatment, too, so whatever “it” is isn’t always depression.
I'll make a wild and insensitive guess here: Try seeing a southeast Asian therapist. Western culture is firmly mired in the incoherent Platonist concept of "perfection". This justifies the Western idea that it's immoral for doctors to try to make patients "better than well", where "well" means "average". It's seen as hubris, as trying to rise above your place in the Great Chain of Being.
This Western obsession with perfection, not just as an aspiration, but also as an obligatory moral limit on aspirations ("flying too close to the sun"), may be why surveys have shown ( https://www.liebertpub.com/doi/full/10.1089/hum.2019.197 ) that Asians are more open to gene therapy than Westerners. It may also explain why Western fiction characters are usually based on "flaws" (deviations from perfection). Buddhism and Hinduism also have the concept of "perfection" at their roots, but Asian and Indian heroes can, like the anime and videogame heroes introduced from Japan, always level up (maybe even after attaining enlightenment). Bollywood movies don't have "superheroes" (aliens or genetic mutants who are literally super-human). Instead, they have humans who are just MUCH better at everything than average humans.
It sounds strange to me for perfection to be set against all-around excellence, but maybe it does work that way.
It would be more plausible for perfection to be opposed to eccentric excellence.
I've heard complaints about difficulties with getting PT to get full function back rather than just vague adequacy.
This is liberating on so many levels. I appreciate your response. I’ve needed to hear this for quite a while.
In particular, there's bipolar 2, a sort of bipolar where the manic part is very small. One of my friends got snagged by that one-- if you have bipolar 2, treatment for depression can make the depression worse. I think one of the symptoms of the manic phase is racing thoughts, but this should be researched.
Could also add to the nutritional section something about how probiotics are suggested to help depression: https://newsroom.ucla.edu/releases/changing-gut-bacteria-through-245617
It's preliminary, but also a very benign intervention if you just tell someone to try and eat more probiotics. Very limited risk there, unless you're lactose intolerant I suppose...
Lots of non-dairy probiotics out there, fortunately! It does take extra looking to find them, sometimes, though. I get Bio-K liquid, soy based (yummy mango flavour).
"except by drilling a hole in your skull and injecting it directly – something which cures depression reliably when scientists do it to rats"
This was funny, but the imagery made me feel squeemish
I appreciated the sentence, as it made it clear why this form of therapy is not used even though it works.
The “cures... reliably” part made me wish doctors did this more often. Preventing the trail of damage created by depression might be worth a little hole in the skull.
After all, what's a little hole in the skull between friends?
In rats.
Probably wouldn't work quite that way in humans, also it might feel awfully weird if the dosage is wrong.
Hey, at the very bad times, I'd happily let them chop off my head. What's a little drill hole by comparison?
This, but unironically. I keep saying I want to try ECT and my psychiatrist, who last looked into it 30 years ago, basically has fits of revulsion and more or less says "hell no." I need a referral. Maybe it's time to try another doctor.
No mention of post-natal depression. Is that deliberate?
Having a baby makes lifestyle changes, showing up to therapy appointments, and (if you're breastfeeding) medication usage more difficult and thus is probably not Intro-Level Treating Depression.
Well, life comes at you fast sometimes. If Scott doesn't feel like he can address post-partum depression well, then he probably shouldn't try, but it's a phenomenon that women deal with every single day. Both the lack of slack to try changes in lifestyle (it's still hard for me to find time to exercise with a 5-year-old) and the cultural valences around how motherhood should make a woman feel happy & fulfilled make offering a lifeline and a sense that post-partum depression can be treated of particular value. I imagine that both of those factors make that kind of depression feel particularly suffocating and paralyzing.
I agree with you- this seems like a major oversight. I also know women who experienced depression after a lost or terminated pregnancy, not just because of the circumstances, but also because of the hormonal fallout.
I've been really impressed by the effectiveness of SAM-e. I take it pretty regularly when I'm feeling depressed, and it works wonders.
It's also worth mentioning that SAM-e is prescription only in Europe, at least according to Wikipedia.
s-adenosyl-methionine-e doesn't appear to be listed in the BNF, and you can buy at least one brand of SAM-e on Amazon UK, so I don't think it's prescription-only in the UK, at least.
My main initial reaction is: who is the target audience for this? As a nerdy SSC/ACT fan I love it as a ‘much more then you ever wanted to know’ post, but I’m not sure how, say, a person wondering if they might be suffering from depression would read this?
The audience for this blog reports an unusually high incidence of depression.
This was my question too. I'm assuming the audience at Lorien Psychiatry is generally people who are *not* SSC/ACT readers and who have come to the site looking for clinical mental health information when they may have very little prior experience with diagnosis or treatment.
As such, there's a bit of a thread of "trust your intuition" and "you'll just know" that I think you need to tee up first -- this (presumed) audience may be used to looking to a clinical website specifically because they want someone to tell them The Answer to their problem. The thing that you're offering that is different is the idea that with the information you are giving them, people might be able to figure out The Answer themselves, but I think you need to frame that first as it may not be a familiar concept.
Relatedly, I found the pronoun switching distracting -- sometimes you talk to the reader as "you", but sometimes you are talking about someone who.is not your reader ("they"); and sometimes you're "I" and sometimes you're "we". I think it might work to just stick to "you" and "we", and you can perhaps footnote the "I" statements which tend to be you (Scott) basically being the source/reference for whatever statement you're making.
I got stuck right at the beginning with a sentence in the second paragraph and suggest some changes: "Chronically depressed people live almost a decade less than non-depressed people, and there’s increasing evidence that this isn’t just because... " should really be "may live almost a decade less" if you're only going to link to the single study. It would be better if you can find several studies that show different reductions in life span, in which case you might say something like "...may live xx to yy years less.." and provide a couple of links. I just don't like being super declarative based on a a study where a third of the participants were age 50 in 1952. For the second clause, "increasing evidence..." links to a single study from 2001 -- it would be better if you could layer a couple of more recent citations there to support that statement.
Regimen 3A/3B imply "Person with/without access to a doctor, high time/energy budget" but might be worth calling that out explicitly as with 1 and 2.
Typo: adapting -> adopting. (I still have to triple check those words in my head every time I try to use one of them.)
Typo: The following sentence from 2.1 repeats 'enough' and uses 'give' instead of 'gives': "If you have zero willpower, not enough enough to be the seed for a tiny investment, then you should start with medication and only pursue willpower-requiring strategies if the medication give you that first little seed of willpower."
"brain areas that regulate your emotion" -> arguable, but probably you meant "emotions".
Typo: "how it works on a neurological, biochemical, and cognitive levels" -> plural vs singular conflict. ("a" vs "levels".)
Typo: pasttimes -> pastimes; "You should try your hardest to do it anyway" - missing full stop (period).
I wonder whether another format for copy-editing would be superior, such as a wiki or github that commenters can propose edits to, but only Scott can approve them.
This is a very good suggestion. I am a copy editor, and would happily do this for free, but copy/pasting errors is just too time-consuming. I imagine also on Scott's end, making use of the corrections.
Refridgerator -> refrigerator.
How nerdy/STEM-educated/comfortable with technical vocabulary do you expect the audience for this page to be? I enjoyed the discussion of depression as an attractor state in a dynamical system, for example, and enjoyed your longer post on that too; but for someone less mathematically inclined, I worry it might seem so jargon-y or academic as to make them less likely to read on. I unfortunately don't have good enough theory of mind about non-mathematically-inclined people to tell whether this is a justified worry. But I do recommend that if you want this to be attractive, engaging reading for people less nerdy than the typical SSC reader, you should seek out some such people to give you feedback.
I strongly agree with this.
I really enjoyed reading this introduction to the management of depression, and consider it to be one of the best I have encountered.
However I suspect that many actually depressed people/people outside of the ACX sphere would find some of the language and thought-processes challenging. Although this is mitigated in some areas by explicitly explaining the process, as with the explanation of priors early on.
It's important to keep in mind that average reading age is still hovering around that of a bright 12 year old, and it seems likely that even a bright 12 year old would get bogged down at some points in this discussion.
That said, there is a lot of good, clear and well explained material here. Scott's efforts to be both comprehensive and lucid are very much in evidence.
Maybe highlighting in yellow the parts that are easier to read?
I agree about comprehensive and lucid.
Or conversely, outline in red the parts that are technical/scary and totally skippable.
Might this actually be a good thing? I suspect that the sort of person who'd read this, while perhaps not familiar with dynamic attractor systems or whatever, will find these sort of words to be at least a breath of fresh air compared to the usual CBT-derived pop-psych that shows up when you google the issue, to say nothing of the endless deluge of Top N Things to Do When You're Depressed.
I don't know if it's just me, but I tend to slot math-y and social science-y terms I don't understand into different mental buckets - "complicated, but rigorously investigated concept", and "ah, the humanities are at it again..." respectively.
I'm not sure that I count as "non-mathematically-inclined", but for reference I don't care for chess and failed College Algebra at least 3 times. My education is a couple of years as a philosophy major before dropping out. I'm better at math now (mostly stats stuff for work), and I do some light coding (mostly JavaScript), but I'm not math-inclined. I think the level of technical terms is about right.
I'm going to have my wife (degree in speech-language pathology) and sister (masters of library science) give it a read as well; they're less tech nerd than I am, so I'm interested in that feedback.
I think the structure is very helpful; you can skip a lot of the explanation and scan up and down pretty easily. I especially like the "stuff to try" section; easy to read. Might help to link back to details on the medications above? The best thing is that it's probably the most straightforward single page I've read on MDD, with a good overview of the state of things and clear recommendations, backed up well with good sources.
I found the first paragraph that mentioned the attractor state paradigm felt somewhat out of place. It isn't a concept most readers would be familiar with, and although probably interesting to a lot of readers, it also doesn't provide enough detail to understand what it's talking about. I would suggest at least adding a link to the longer discussion on the topic--otherwise bringing it up just adds confusion and wastes the reader's time.
Agreed, the "attractor state in a dynamical system" piece threw me too. I appreciated the analogy, and yes, it did clarify things for me... but... I happen to at least have heard of the concepts of "attractor" and "dynamical system" (heard of, never actually calculated, mind you). I can't name any of my friends who can say the same.
I should add that the same sentiment applies to the organic chemistry portions of the article.
I'm a practicing mental health professional (clin psychologist in Aus) with a PhD in modelling cognitive processes. I can guarantee you are right. I spend a fair bit of time translating what GPs (Physicians) and Psychiatrists say to clients, and what clients read online.
We have a pretty good NFP in Australia called black dog institute which has some good MH resources. It is pitched at a typical client level. I often send ppl there.
this is a great read for clever folk or fellow professionals though. depends on the target
FWIW, I do not do dynamic systems, but I think there was something bit off with the language about attractor states. While the overall point made sense to me because I have read the ACX post where the idea was first discussed, I could have not parsed the paragraph's meaning without that context.
Specifically the irksome parts were here:
>On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
I think in applied mathematics people prefer to say that the "mathematical level" of the dynamical system *models* the physical ground reality. Especially so if the dynamic system in question has inputs from as different categories as biochemistry and life events.
Also, what edges, which graph. One can combine dynamics and graph approaches but it is not immediately obvious to me how? Again, re-reading the original dynamics idea post helps: https://astralcodexten.substack.com/p/ontology-of-psychiatric-conditions-34e the graph probably refers to the graph representation of correlations between the symptoms.
I would have had no idea what Scott meant by attractor state if I had not read his previous piece about it
Trying to bring up neuroendocrinology objectively in the modern era is unfortunately frequently academic self-immolation- but I think it might be worth it. Eg NDRIs and testosterone, PMDD and temporal SSRI scrips
Just as a first pass-mainly cause my startup just got a deal with Sage/Biogen and they have some of the first endocrine based treatments
Why is it academic self-immolation? Are people against it?
Since anecdotes are acceptable here: I’ve seen a single 300 mg shot of testosterone in the buttcheek change the life of a few older men.
I’m not depressed, but if I ever find myself in that state later in life I might give it I try.
Testosterone has a large antidepressant effect. Perhaps this accounts for the difference in prevalence of depression between men and women. Most people don't get enough zinc, magnesium, and vitamin D and can raise their testosterone a bit by getting more of that and lifting.
My PubPeer plugin tells me you're quoting an article which has a worrying comment on PubPeer (the comment is from a bot which outputs warnings when the summary statistics seem weird, and should probably be checked). Weirdly, I can't find the relevant link in your article right now, but here is the comment if you want to check: Updating positive and negative stimuli in working memory in depression (https://pubpeer.com/publications/0DD5CCD0457CAF07AAB1E74607D109)
One thing that's helped my wife is consumption of a sugar called inositol, which is about half as sweet as glucose, IIRC. It helps with rather specific types of depression. An issue with inositol is intestinal absorption which limits the amounts used in some studies or dietary compliance. But alpha-lactalbumin assists with asborption to some extent. Alpha-lactalbumin is a component of whey.
One of the effects of lithium in people with bipolar disorder is to reduce inositol concentration in parts of the brain.
In one spot you list SAM-e but the rest of the time you drop the hyphen (I don't know which is correct)
Probably without. It's an abbreviation of S-adenosyl methionine, and I think it originates from the 3-letter code for methionine, which is Met. So it should probably be "SAMet" but "SAMe" is better than "SAM-e" which doesn't really make sense. Since it functions biochemically most often as a supplier of methyl groups ("Me" groups) this also makes a little more sense chemically.
On the other hand, if you google "SAMe" you will get about a billion hits that think you were typing the word "same" so...maybe "SAM-e" helps get you through the mindless algorithms.
Exactly! Never mind trying to convince your stupid iPhone to stop 'correcting' the word ..... Damn I still miss my Bby.
You seem to hint at the idea that depression that comes from anxiety is different. How would you approach it differently? And is it not common for depression to not be tied with anxiety? ( thought they were frequently comorbid.
Depression is sometimes the result of a vicious cycle of failure causing low self-esteem causing failure. Methylphenidate works surprisingly well for escaping the cycle.
Foods high in carbs reliably give me brain fog, anxiety, and short-term depression for hours after eating, so the mediterranean diet recommendation would make my depression worse. Fruits and meats don't have these issues for me. If anyone can diagnose my dietary condition based on this description, please do.
Have you tried cutting gluten from your diet? I’m guessing the answer is yes given the popularity of gluten free diets, but if specifically the issue is carbs high in gluten (mostly wheat products, some other things) that would make some sense for Celiacs disease.
Google tells me rice is gluten-free, but rice is one of the worst offenders for me. To completely eliminate the possibility I should probably find a low-carb source of gluten and try it with meat. Eating lots of carbs seems to cause low-level inflammation all over the body e.g. muscle and joint aches. I seem to have a problem with specific types of carbs as I can handle fruits just fine. My best guess is that some sort of filtering process in my body is not working properly. My genes are from populations, which do not have a long history of eating grains.
Seitan is basically pure gluten.
In relation to Scott's portion of nutrition, I was also somewhat surprised by this endorsement. I think this section could use a little more elaboration, particularly on the connection between inflammation and depressive-symptoms.
https://www.medicalnewstoday.com/articles/326838#:~:text=The%20idea%20that%20inflammation%20may,more%20inflammation%20in%20the%20brain.
I'm tentative to include this because, like Scott mentions, the research is pretty shoddy and already scarce, but I think it would be worth considering adding a brief introduction to an elimination diet for people that may be experiencing adverse bio-psycho symptoms due to some unknown product they're consuming. This isn't intended to be even a tacit endorsement of the ketogenic or carnivore diets, especially considering how each sub-community of the low-card tribe is so vitriolic to one another despite the fact that they're unified in their lack of established science. With that being said, there's enough anecdata to suggest that there's something worth investigating.
My only concern with this ties into a central theme of Scott's writing here, which is that modifying one's nutritional approach can be hard, especially if one were to endeavor on something like the keto diet. This can then perpetuate the self-defeating cycle of depression, which just makes things worse. Any thoughts on this?
Vitamin C powder; cutting out refined sugar, most meats, coffee, dairy, and soda; yoga; and skateboarding work for me
Re. "You can address the social causes by changing your life circumstances (and research suggests people underestimate the potential benefits of making major life changes)."
This is more true if by "people" you mean psychologists. I had severe depression in the years around 2000, and it recurs when bad things happen in my life. I wrote psychologists off forever after several attempts, because whenever I talked about what I saw as my life-circumstance problems, they would try to get me to think or feel about them differently. They tried to talk me out of my attempts to remove what I saw as the causes of my depression. They said that the belief that improvements in your circumstances would make you happier was a trap, like thinking that earning more money could make you happier.
In related news, earning more money can make you happier.
Sorry you had to deal with that! Glad you managed to break out of it, or at least see through it!
That said, I think this is plenty true even if one just means non-psychologist people. As a data point, when I rearranged my life while being B12 deficient (and oblivious to it) and very depressed, I was *expecting* those changes to make a big difference, *and they still made a significantly bigger difference* than I had been expecting them to make. Since I don't actually know anyone who is more generally-optimistic than I am, I absolutely believe that this is a common tripwire.
Wow, sorry to hear you met so many crap psychologists! Any noticeable factors that would indicate which to stay away from; were they young (and therefore perhaps inexperienced)? What level of training, type of training?
Well, they used cognitive behavioral therapy (CBT), which was all the rage then. But also, "several attempts" here only included 2 multiple-visit attempts, and only 1 that was more than a month in length. After that, I found a really shady psychiatrist who did nothing but prescribe pills to Vietnamese patients (plus me). She prescribed me bupropion after a 5-minute visit, and that worked so well that I didn't bother with psychologists anymore.
I seem unable to be depressed for more than one day. This might happen once, maybe twice in a year. My strategy for that day is basically to stay in bed and eat potato chips. Next day I'm back to normal. Is there something wrong with me?
No, this means you are a healthy person who doesn't have major depressive disorder.
Congratulations, for your free prize please accept this smack in the chops.
I do get the impulse to make a joke about this; after all, doesn't every one feel a bit down, a bit blue, now and again? What's with this "oh I'm depressed" craze? After all, if going for a walk in the fresh air makes you feel better (Official Medical Advice), isn't the reasonable thing to just say "pull yourself together" instead of indulging in notions of "no, this is depression"?
When you've literally slept for 36 hours straight because you are too dazed to drag yourself out of bed (except to the bathroom and then fall straight back into bed), come on here and talk about how staying in bed resets you back to normal.
The bad times are very damn bad.
Immunity to depression is probably worth studying, but possibly not here.
Aren’t most people “immune?”
I don't know. Most people are probably immune a lot of the time, but some people don't get depressed even when it would seem likely considering their circumstances.
Depression is a maladaptive human response, not a normal or inevitable one; neither is it a communicable disease, per se, so it seems odd to speak of "immunity" in this context.
> Depression is a maladaptive human response
Is it though? How can you be so certain that it was never adaptive?
There’s a few hints in there as to why you have issues.
Yes. It is because my brain is banjaxed.
Boring edit: refrigerator spelled wrong
Thank you! Have you done anything like this but for anxiety/depersonalization ?
I think the “what is depression” section to be pretty jargon heavy. I’m a medical student, and if I ever heard someone say “psychomotor” in one of our exam practice sessions I’d call them out on it because patients don’t know a lot of the words that we get taught, or at least aren’t able to figure out on the fly. For instance, I recently saw some paediatric cardiologists tell a parent that their kid’s aortic valve was prolapsing into hole in their heart. I appreciate they said “hole” rather than “ventral septal defect”, but I’ve never heard the word “prolapsing” outside a medical context, and lots of people don’t remember their high school biology cardiac anatomy enough to know what an aorta is or how valves work.
I could just be underestimating my patients, but I’d try to use more accessible language in that section at least
I was thinking that a lower vocabulary version might be called for. I could read it, but my vocabulary is larger than most.
I expect Scott's posts, even at Lorien, will always end up best for people who have bigger vocabularies than average, and more tolerance for jargon. But in particular I would suggest that "psychomotor retardation" is a phrase that's likely to cause a lot of confusion and misunderstanding, and I would probably at least reverse that bullet. (That is, start the bullet with something like (from Wikipedia:) "visible slowing of physical and emotional reactions". Then if you want to include the jargon term, do it in the parenthetical, rather than the reverse.) Normally I'd expect people to be able to deal with the "jargon (explanation)" format, but "retardation" is a word whose technical meaning is almost unheard of in common parlance, and whose colloquial meaning is very emotionally charged.
I’d saw some links on how anti-inflammatory drugs can be used to treat depression. Twitter search: @degenrolf depression or @degenrolf anti-inflammatory is where I found it
https://twitter.com/degenrolf/status/1111568424378007553?s=21
Depression in men is one of the symptoms of low testosterone and testosterone levels have been falling 1% every year for a long time now, so it's possible that a lot of male depression is due to low testosterone.
The problem is made much worse, because most labs (at least here in Europe) don't have age-adjusted ranges for "normal values", so a 20 year old guy would have to have the testosterone level of a 90 year old suffering from erectile dysfunction before a diagnosis of low testosterone is made and supplementation is offered.
I talked to a medical doctor about this. He is recognized as a leading authority on these issues here in Estonia and is often in the news. He said that falling male testosterone levels are good for society and therefore he and his colleagues have decided to only treat cases, where low testosterone directly and clearly affects reproductive health. Depression and other less important symptoms he leaves to other doctors.
I also suspect much of it is due to hormonal problems. Very foolish that he and his colleagues believe this, there is more that comes of high testosterone than youthful aggression.
My sense is that Western low testosterone is overdetermined. If I had to guess though, the main contributors are EDCs, mentality, stress (resilience), and obesity/exercise. Treatment modalities might be:
- EDCS: eliminating all synthetic toiletries, eating organic, washing hands frequently and not mouthing them (apparently common), if in USA reducing meat consumption generally (atrazine is really bad and gets into almost all animal fat from the water table, organically fed or not) in favor of fish, and finally slowly replacing all plastics and synthetics that one touches / stores food & drink in with cotton/ceramic/steel/etc.
- Mentality: I'm pro-feminism but I think it's fair to say that it has led many men to adopt lifestyle choices (eschewing overt status, favoring collaboration over competition, being more relational and empathetic, socializing with women) which all empericially decrease testosterone. My POV is that Western men should keep the feminism, but become "feminized" at their peril — our society had norms against men adopting these behaviors for a reason.
- Stress: I doubt stressors have changed much, but many have become much worse at weathering them. Say what you will about the "Flying Spaghetti Monster" and the value of individualism, decreases in religious practice, communal bonds, and family closeness seriously injure resilience to stress. Additionally, many young people have been raised in protective environments where responding to stressors histrionically is rewarded — not good for resilience. I know many dislike religion because they don't want to accept the truth claims, but IMO most unbelievers would still get big benefits if they just went to the Church/synagogue/etc they were raised in once a week and did the rituals. For those who were raised atheist, I bet Jungian active imagination/etc would work, you'd just need to find people to go along w it (apparently in the 90s this was popular, guys would get together and dance in the forest talking about archetypes under the auspices of the Mytho-poetic mens movement). If not, some of the more woo-ish meditation traditions probably would work.
- Exercise/obesity: It's well-known that visceral fat leads to testosterone decreases, and endurance training and resistance training both probably lead to modest improvements either via decreasing fat or just by decreasing stress or possibly via some other idiosyncratic mechanism (skeptical of the latter personally).
I realize a lot of these recommendations seem less than politically neutral — the recommendations all quite right-wing adjacent. I don't think this is a bias on my part, I actually think that for men testosterone seems to have a causal role in influencing politics. There are some studies that validate this, but for me it is anecdotally obvious. Very rarely have I met a man with traits of low testosterone who has been right wing, and the converse is even less common.
> He said that falling male testosterone levels are good for society and therefore he and his colleagues have decided to only treat cases, where low testosterone directly and clearly affects reproductive health.
WTF? I'm baffled as to how a medical doctor feels he has sufficient expertise, let alone the right, to enforce that kind of conclusion. Doctors should be concerned with health.
It may be worthwhile to add a section on ways to help prevent depression from occurring in the first place. That's one of my concerns as a fairly neurotypical person; I really would like to not become depressed, since the condition works against you seeking out ways to improve yourself.
cutting out soda might result in caffeine withdrawal (some people who drink a lot of soda all day), which could make depression or anxious symptoms worse in the short term.
maybe worth warning about this and suggesting green tea or something?
Whoa, now you're playing hard mode. Nice read! Some comments mostly on the non-medical parts:
I'm not quite sure why you are treating hypomania as a bad thing in 1.2.1 (at least the sort that contents itself with messing with one's emotions rather than encroaching on one's perception). I'm aware of the specific problem with suicidal people getting more likely to try it out when out of depression, but should the rest of us worry? If I am to name what's wrong with the world, overconfidence isn't what comes to mind. But I guess there are some things that become hard to say once one calls oneself a doctor (thank goodness a PhD does not count).
I wasn't aware of the Levitt study you referenced in 2.1.1. That might be useful not just for the depressed? At a quick glance ( https://www.nber.org/system/files/working_papers/w22487/w22487.pdf ), there does appear to be a selection bias issue here: a study on Freakonomics and MR readers will necessarily have a certain kind of slant that may make its conclusions -- such as the incredibly high happiness returns on starting a business -- somewhat less generalizable than one might hope for. Still, if there is an effect here, yolotherapy might be the next big thing. (Though oracles and fortunetellers might have been living off the same land for millenia; this study should be lauded for observing the same effect in some of the groups least likely to use the services of the former.)
Mediterranean diet. Someone is going to retweet the hell out of this.
2.1.3: In my experience with something-like-depression (I think there should be an IANAL-like disclaimer for discussions of undiagnosed psychological symptoms, particularly when one doesn't even believe one has the real thing), I found hiking helpful... for the duration of the hike. The effect dissipated on return, probably because of the transient nature of the whole thing. On the other hand, far-from-wholesome nerd work (think coding until 5AM) worked like a charm if there was something tangible to show at the end. Neither to generalize nor to pollute the data, but I feel that there is some kind of internal accounting of accomplishment and progress involved that is not easily tricked. Maybe serious gamification (Pokemon Go?) could help, but unless you manage to forget the artificiality and sideshow-ness of the attained achievements, it's likely to be a hard sell to the "you suck" mob inside your mind. (Preemptive "don't worry about me" to the commenters here; I am doing fine and my symptoms have always been subclinical.)
2.3: "If neither of them work, and you’re feeling optimistic" hehe.
I'd have wished for some discussion of tolerance in 2.3 and 2.4. Is it less of a thing than I expect it to be, or is less about it known?
Typos: "pasTTimes" (did the proximity to "hoBBies" lead you astray here?), "refriDgerator" (wouldn't have spotted this one if the "d" didn't stand out so awkwardly in a Latin root), missing period after "hardest to do it anyway", "only proportional" (should probably be "proportionally"), "enough enough".
>I'm not quite sure why you are treating hypomania as a bad thing in 1.2.1 (at least the sort that contents itself with messing with one's emotions rather than encroaching on one's perception). I'm aware of the specific problem with suicidal people getting more likely to try it out when out of depression, but should the rest of us worry? If I am to name what's wrong with the world, overconfidence isn't what comes to mind.
Hypomania isn't just overconfidence. It's a pattern of being insensitive to the risks or costs of one's actions, along with, yes, overconfidence and a strong drive to achieve and to try new things. Yes, it can be fun, but it can also lead to a lot of pretty horrible consequences that the manic person will end up regretting. Arrests, divorce, going into debt, getting fired, are all possibilities.
Well, all of these seem to have a greater upside according to the recommendations given in 2.1.1. Of course, there is an optimum in the middle here, but I have the impression that the modal reader of the post will be below it.
2.1.1 supports the claim that making big life changes can be helpful for depressed people. It does not support the claim that mania/hypomania is innocuous. You might want to read about what it's like to be manic, because you seem to be seeing only the positive side of it (confidence, ambition) without noticing the possible psychosis, violence, anger, agitation, and deeply destructive choices that *can* come with mania.
I'm talking specifically of hypomania, not mania. At least by its modern definition (DSM-5 according to WP), it is a pure mood state, with no psychotic symptoms attached to it; one retains full awareness of what is happening and full control of what one is doing. If this is the worst that can happen from overcorrecting a depressive phase, I'd say it's a good deal.
Of course, there is a legit question underneath here, which is whether mania and hypomania are typically caused by different underlying factors, or differ only in the strength of the condition. My impression is that it's the former -- I would be surprised if hallucinations just emerged out of sufficiently high euphoria -- but this is for psychologists to answer. But I for one would happily trade a mild depressive episode for a hypomanic one.
Beyond the potential negative consequences of actions taken while hypomanic, I think the typical model is that hypomania does permanent accumulating neurological damage. [It might be fine this time, but that makes it worse next time, and so on.]
I want to know more!
>German studies tend to do the best and American studies the worst, which might either reveal something about those countries’ cultural biases, or about the different strains and extracts of the plant used in the two countries.
I heard on a podcast that the difference is likely that St. Johns Wort supplements are regulated in Germany, and not so much in America. Which would mean German St. Johns Wort supplements are much less likely to be adulterated.
Can anyone recommend a good German extract of St. John's Wort that you can buy in America?
I don’t know any German St. John’s Wort but I’ve been talking the herb every day for three years since the Paxil I was talking started affecting my thyroid and I would include a warning about cheap extracts. They have no effect in my experience.
pretty sure you can order anything from amazon germany and get it delivered to almost any place in the world, including the united states :-) Regarding a "GOOD St John's Wort extract" .. never took it, so no experience with it. If you want to check for yourself, here it's called "Johanniskraut" or "Echtes Johanniskraut", you might want to look for a "Bio" label, that's similar to what you guys over there call "organic", unaltered, no pesticides etc.
from a quick glance i would say these look trustworthy:
https://www.amazon.de/Johanniskraut-Extrakt-2000-inclusive-nat%C3%BCrlichem-Hypericin/dp/B06W9L66D7
https://www.amazon.de/EINF%C3%9CHRUNGSPREIS-Kr%C3%A4uterhandel-Sankt-Anton-Johanniskraut/dp/B07QLQRMJQ
https://www.amazon.de/Nutri-Johanniskraut/dp/B085G7S1SQ
Gaia herbs has an “emotional balance” formula with St. John’s wort in it. Seems to help in one kid but the pills taste herbal and so he takes 1 where 3 would probably help more.
German here. what regulations exactly did they talk about? I don't know of any, its considered a "normal" supplement here, you can order the dried herbs for tea or the extract, extract is typically in the 2000-4000mg range
Well, as I understand it, in 1984 St. Johns Wort was approved as a treatment for depression by Germany's Commission E. Which means doctors can prescribe it and as far as I can tell makes prescribed St. Johns Wort fall under the normal German drug regulatory rules.
In contrast, the Food and Drug Administration has not approved St. John's Wort as a treatment for anything, and it is classified as a dietary supplement, not a drug. Which means producers of St. Johns Wort in America fall under fairly lax regulation and enforcement as far as purity goes.
i checked it, you're *somewhat* right: there are a few products that fall under the described regulations, but the majority is freely available. the categorization is bizarre if you ask me, it is not the amount of St. John's wort extract contained in the drug or its effect or something similar that is important, but only the declaration of the intended use. That is, products intended for the treatment of severe depression are medications and therefore require a prescription, while products for mild and moderate depression are considered dietary supplements and therefore freely available on the market.
I guess the real question is which kind of St. John's wort did they use in the studies that found it was effective? I would assume the prescription stuff, but that's only an assumption.
This is generally excellent.
However, on first reading the beginning section - "The short version" - read really oddly to me. It seemed peremptory, confusing, and almost flippant. I may not have any idea if I'm depressed or not, and suddenly I'm being told to consider a Mediterranean diet, methylfolate AND electroconvulsive therapy! However, once I had read the whole text, I reread this section, and this time it seemed fine. So IDK... but maybe consider expanding it a little and clarifying to the reader what the section is.
The "What is Depression" segment perhaps assumes a bit too much knowledge in the reader. I was trying to put myself in the shoes of someone who feels depressed but doesn't know much about depression, and I wondered if such a person would necessarily follow the use of quotation marks as a compressed way of referencing a whole complex area of what constitutes a real symptom, what psychosomatic means etc. I would consider laying out the issue briefly but explicitly rather than in this more coded form.
With your use of humour, I felt that at moments you were a shade too close to your blog style. In particular "being a moron", and "because the researchers were cowards", plus maybe the hole in the skull bit. I found these funny, as usual, but I wondered whether someone in a vulnerable state might find their trust in your otherwise very steady and reassuring voice undermined a touch.
The writing is refreshingly free of jargon. Exceptions were "modality" and "high withdrawal potential", the second of which I took to mean that it had danger of withdrawal symptoms, but I wasn't certain.
This sentence -
Some people act like the episode “continues under the surface” even when a medication is treating it, and if you restart earlier than this, it will show up again.
- for some reason I found it hard to follow and had to read it three times. I can't find any syntactic or stylistic reason why this should be so, so it's probably me. Maybe I'm depressed?
In the passage about the mathematical explanation, maybe you should link to your attractor posts? For someone without much maths it would be hard to get a sense of what the passage means.
Finally - and this is something you know approximately a million times more than me about, so apologies for the presumption... but I wondered if there should be more in the way of caveats? Particularly when it comes to medication, you say "You should consult with your doctor" but don't really stress that they shouldn't start necking escitalopram-ketamine-and-St-John's-Wort cocktails without seeking more advice first. I worried that someone like my cousin, who is not always depressed, but is always a total maniac, might just immediately get on the dark web and buy the whole list.
Typo in 2.1 - "enough enough"
> Some people act like the episode “continues under the surface” even when a medication is treating it, and if you restart earlier than this, it will show up again.
I was a bit confused by it, too. Perhaps "act" is a bit ambiguous here (at first I understood it in the "pretend" sense).
I agree with this feedback 100% - I'd start with the short version with a very short and practical definition of depression, how you know you have it, then go to how to treat it.
> Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
This entire paragraph is very hard to parse for the non-mathematically inclined. I'd suggest either toning down the jargon or linking the hell out of it so that readers who don't understand the technical terms can go read a writeup of how that math works.
Additionally, the diet stuff looks *awesome* but there's enough to that section that you may want to make it its own page. Note how you went into a 4th level of numbering--typically that's a good sign that you've gotten technical enough that it should be its own page that you link to on the main page.
Although I understand the basic idea of the dynamic system paragraph, having read the explanation at https://lorienpsych.com/2020/11/11/ontology-of-psychiatric-conditions-dynamic-systems/ , I agree that it is probably more technical than it needs to be. I still don't know what "weights of the edges of the graph" is supposed to mean (I'm picturing a dynamic system as a curve on a multidimensional Cartesian graph, but I can't tell what would be meant by the "edges" of such a graph), & since this doesn't go into the math in any detail I'm not sure that it wouldn't be better to just write it less technically as something like "Depression can be understood as a set of several sorts of life events & biochemical factors which tend to occur together & reinforce each other, so that the overall state of depression is difficult to change & various subsets of these factors can, by bringing about related factors, shift a person into depression."
Thank you for the link because this is fascinating.
I did want to recommend rewriting the paragraph completely to remove all mention of this mathematical model as well, but I came to the conclusion after the diet section that this would be counter to Scott's purpose of offering as much information in as many formats as possible.
This much information may cause overload for the casual reader, however, so it may just be enough to provide the link you did and say "if highly technical mathematical things make a lot of sense to you, check out this model of depression."
When Scott says "graph" here, he doesn't mean a Cartesian grid (like you'd find on graph paper), but a graph as defined here: https://en.wikipedia.org/wiki/Graph_(discrete_mathematics)
Calling this a "graph" is normal in mathematics and computer science, but for the layperson "network" is probably a much clearer term.
In this context, "edges" are connections between nodes in the network, and the "weight" of an edge is a number associated with it, indicating how "strong" the connection is, in some relevant sense depending on the specific problem.
I already wrote it above, but IMO the issue is not that graph theoretic concept of graph might be unfamiliar to the reader, but the graph itself is simply not defined. What are the nodes of the graph? The text here does not say. How the graph is related to any dynamic model? The text, as is, does not say. My recommendation would be to define what the concepts refer to.
As a plus, the non-mathematical use of the word "dynamic" is a swamp of dynamic business jargon, it would help to be precise.
Here is an introductory text that manages to explain attractor states (for ecologists) with only single use of "dynamic": https://passel2.unl.edu/view/lesson/bcbd3f35f2e0/2
Really like the doc! It's really valuable putting all your expertise into these articles & think it will eventually be the Paul's Notes of Psychiatry.
I don't think this paragraph adds anything for the vast majority of people reading it and it just kind of hangs there without being connected to anything else:
> Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
Second this
Third this.
Lots of people are a bit scared of mathematics, and this para doesn't really add a lot for the average reader - and it may be just one step too far into the technicalities for many.
Maybe would make more sense if he links it to his ACT article on this (or, since I imagine he wants to keep these separate: copy over that blog post into Lorien?)
Maybe I've read too many oversimplified depression guides, but I find this level of complexity to be refreshing. I think it could even be *more* technical, to be honest. I don't imagine Scott's strength is in writing "a good article for 95% of people" but rather "a great article for 30% of people."
DOG.
Get a dog. :P
CAT. Down with dogs !
I don't like dogs, but they seem to be better for people with depression, just by observation.
The dog reminds you to get outside the house and go for a walk twice a day.
Other material I've read makes a hard distinction between mild-to-moderate depression and severe depression, with the later being more amenable to treatment. No?
I think rhodiola extract helps. Worth researching?
I've found that the best thing for self-hatred, though not a complete solution, is to identify with the self being attacked rather than the attacking voice. Saying to myself that the attacking voice is factually wrong wasn't especially helpful. It's more feasible now that I'm less identified with the attacking voice, but it wasn't a place I could start.
One of the nasty things about diet is that the taste of sugar cuts through the depressive haze better than most things. I don't know whether there's a general solution for that. Fortunately, I'm able to take it seriously that too much simple carbs makes me feel bad.
Loved it and more helpful than anything I've read since coming to understand this was a trait in my wife's family... nit: 'pasttimes' not a word, s/b 'pastimes'.
You briefly mention wake therapy, but you do not mention the symptoms that suggest it might work, as described in your post https://astralcodexten.substack.com/p/sleep-is-the-mate-of-death . Is the omission deliberate? I'm one of those people who feel terrible in the morning, better as the day progresses, and good enough in the evening that I try to delay going to sleep. That post made me seriously consider the possibility that I might be depressed.
Good overview. Though I'd say my major depression comes from hopelessness, feeling disconnected. So there's a lot of existential pieces to it. Also, dunno about saying therapy from a book is just as effective. Sort of discounting the role of interpersonal psychotherapy in untangling and adjusting core beliefs through a real relationship, which can then translate to real world. Thanks for the read.
I liked this a lot! I would increase the emphasis on the fact that major depressive episodes tend to ease up on their own after 6 months. You note this in passing at the end in the context of medication but I found this knowledge super helpful when a doctor mentioned it while I was depressed (and, anecdotally, other depressed people I've known seemed surprised when I mentioned this to them). It helped me reframe depression from something I was failing to fix and made me see it more as something washing over me I just had to survive.
As you say, it feels terrible to be depressed and keep getting advice on how to be less depressed that you know you won't have the willpower to execute. (And if you think you'll feel this way forever unless you miraculously get your act together, suicidal ideations feel much more tempting.) In my case, just telling myself that waiting out the clock was also an option and I probably wouldn't feel this way forever even if I never managed to get on the right meds helped me about as much as anything else I did in terms of breaking the depression spiral.
Broad note: this feels less approachable than your average article, which seems unfortunate in something that depressed people are presumably going to be trying to read. I wonder if there's some way to organize each FAQ item so that it starts with an engaging claim or anecdote, continues with concrete recommendations, and only then goes into the justifications?
> Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out.
This is not my experience at *all.* IME depression is a lot like being abused -- no matter how bad yours is, you probably don't think you're *really* depressed.
> The most common are depressing jobs, depressing relationships, and (surprisingly often) depressing grad school programs.
Presumably massive sampling bias, but the two I see most often are "depressed from living with abusive family" (but convinced that their family is lovely; depression fixed when they move out) and "depressed from dysphoria" (but convinced they're cis; depression fixed when they transition).
> What’s the role of sunlight in treating depression?
I'm perpetually confused about what tradeoffs I should be making on this, as someone depressive who's also very pale with a family history of skin cancer. Should I be covering up on sunny days or taking my shirt off? Do I still get the depression-related benefits if I'm slathered in sunscreen?
> They come from normal healthy eating. Less processed food, junk food, and soda; more whole foods, nutritious foods, vegetables, and water.
I've always figured there's a Maslow's Hierarchy sort of thing going on here, where the base of the pyramid is *actually eating food.* I know a lot of depressed people who struggle to reliably eat *at all*; I wonder if it's worth actively recommending processed junk food in the cases where that might make it easier to get calories in your body while depressed.
Finally, some questions I hear a lot from depressed people which aren't addressed here (I'm sure you've already thought about many of these and decided against including them, but just in case):
- But what if antidepressants turn me into a drugged-up artificially happy zombie who can't feel sad about genuinely sad things?
- If I talk to a therapist about my depression, won't I get committed to a mental institution?
- What if I'm just a genuinely evil person who really should feel bad, and treatment makes me stop feeling bad?
- How can I tell if I'm depressed, or just right that the world is a terrible place hurtling towards destruction and ruled by people who torture babies?
- I've been on medication for my depression for ten years, and as long as I'm on it I'm good, and every time I go off it I become suicidal. But I'm good right now, so probably I was never depressed and this medication isn't doing anything, so it's a great idea to stop taking it, right?
(Okay, no one actually asks that last one. But it sure does come up a lot.)
Those are great questions to address!
Agreed. The "But what if feeling terrible about myself is justified?" one still feels like a genuine issue to me.
Not sure what you mean by genuine issue. It is genuine in that many depressed people feel that way. It is a symptom of depression.
Sometimes we may feel guilt or remorse about a specific harm we caused and that feeling may guide us to make amends and change our behavior. That's the extent of the social value of guilt.
Marinating in feeling bad about oneself generally across days, weeks, and months is a symptom of depression and serves no use to anyone. It is part of the distortion field of depression and is harmful. Believing that feeling terrible about oneself is justified is a sticky way that the ego becomes identified with the symptoms of depression.
Anxious people do this too by believing that their constant worrying is helping to keep them safe in the world or is helping them become better people. These are delusions/symptoms of the problem that become clear once a person is more free from the grips of the anxiety or depression.
By genuine I mean I genuinely don't know the answer.
> Believing that feeling terrible about oneself is justified is a sticky way that the ego becomes identified with the symptoms of depression.
I think it's the *cause* of that particular symptom. Depressed or not, of we didn't feel guilt was justified, we'd just stop experiencing it.
> This is not my experience at *all.* IME depression is a lot like being abused -- no matter how bad yours is, you probably don't think you're *really* depressed.
Seconded. I've had moderate symptoms all my life but didn't acknowledge it until midtwenties. How your environment-culture frames a) your behavior b) depression matters a lot.
> "depressed from living with abusive family" (but convinced that their family is lovely; depression fixed when they move out)
Another data point says hi.
> Do I still get the depression-related benefits if I'm slathered in sunscreen?
I conjecture yes, because getting outside helps all on its own.
> I wonder if it's worth actively recommending processed junk food in the cases where that might make it easier to get calories in your body while depressed.
I speculate "no". In fact, I speculate that fasting might be better than eating terrible junk food. Sugar gives you a temporary dopamine hit, but then you crash when your insulin spikes, which drops your mood further.
Fasting reduces inflammatory markers, which have been implicated in depression, and your body releases cortisol to mobilize stored energy which manifests as more mental energy and clarity.
Furthermore, making a conscious decision to fast gives a semblance of control which can be a little positive victory. Then again, perhaps this should only be done if implemented as a conscious eating regimen where you force yourself to eat proper food when you should not be fasting.
That said, this is all speculative. Consciously implementing and adhering to a fasting regimen has helped me at times, but I doubt I suffer from major depression, so take with a shovel of salt.
I really enjoyed the dynamical systems post, but I think without the massive amount of context that it provides, its inclusion in the short version is confusing.
Which (if any) of these supplements would you recommend for a non-depressed person?
> Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out. On the other hand, if you really like going through checklists to figure out if you’re depressed, you can take the HAM-D, a very official depression test used in studies, and it will tell you exactly how depressed you are.
In my experience, chronically depressed people often assume that they feel the way everyone else feels and are just less virtuous and able to deal with normal life stressors. I've encouraged people I know to take the Beck Depression Inventory and they've found it very helpful with realizing that their situation is abnormal.
It might be worth mentioning eating disorders in the section on the Mediterranean diet, because lots of depressed people have EDs. Anecdotally, a lot of depressed people I know undereat, and getting enough calories tends to improve their mood.
Oh thank you for highlighting that -- I meant to say something like this but you said better than I would: "depressed people often assume that they feel the way everyone else feels and are just less virtuous and able to deal with normal life stressors."
For those who haven't had depression before, there's a boiling frog dynamic that makes it very hard for the person to identify when it's slipped from "going through a rough patch" to "this horror is my new normal and it's not normal and I need help."
The "what the hell is my problem?!?" voice is a big one keeping people from getting help.
It's definitely not my experience that most people know if they're depressed. Often people close to the person will know before the person themselves knows.
Also, reminds me to say: depression for some people mainly presents as heightened irritability. This is true of kids but is also true of some adults. I think maybe helpful to say that somewhere.
I live with someone with hereditary treatment-resistant depression that requires a continually evolving cocktail of pharmacologic therapies. She even went as far as ECT during a particularly acute phase of her depression before we found a new cocktail that has put her depression back in remission (for now).
Given this experience, I am likely biased in how I think about depression. And, with this bias, I found the Short Version a bit...glib? It certainly would turn her off if she were reading the short version. The long version I feel gets the balance far more right, but she might never get to the long version due to the short version's feel. Just something to think about if you're looking to attract and educate people who *are* depressed.
Other thoughts:
Before she did her first ECT treatment, I read up on what it does and how it works intensely, because I was scared of this procedure too. What I picked up was that ECT actually shuts down hyper-active neuron activity, and this made sense to me (but flies in the face of what you state in your long description).
It does appear to me that, when depressed, the patient is unable to turn off the "bad news feed" - and this appears to resemble over-processing, not under-processing, of information.
Further, it seems like a depressed person resembles an incredibly self-centered person as well - a negative narcissist, if you will. The pain they are in makes their entire existence about *them* at all times, which is probably not normal or healthy. Further, I completely agree with the intersectionality of depression and anxiety, but I would like to suggest that sensitivity be added in here as well.
When she is depressed, I witness someone who is hyper-sensitive to stimuli, hyper-aware of self (in a negative context), and constantly swirling in a heated stew of brain pain. It's a vicious cycle. An analogy I use to describe what I witness is that while I go through life in a car with shock absorbers, she's going through life dragging her knees on the pavement. She's just so much close to the ground, with no ability to modulate or buffer the inputs.
And it's this inability to modulate or buffer the incoming data that leads me to the hypothesis that depression is actually about hyper-active neuron activity vs. too little.
Hope this helps.
Strong agreement with the 'negative narcissism' sentiment. At my most miserable, I was more or less incapable of taking other people's needs or desires into account – I was too preoccupied with plugging the gaping wound in my own brain. I went into this in more detail in my own comment, but volunteering at a local homeless shelter was, for me, a more effective treatment than any SSRI.
Obviously, unless your social group is willing to give you a lot of slack, this can feed into a deeply tricky cycle of isolation.
Thanks for sharing. It does make you wonder if there's another angle of depression treatment which is more about forcing external stimuli that demands reaction from the depressed subject.
It also makes you wonder about why crippling depression exists evolutionarily... why does it persist? What we perceive as depression is actually more of a misalignment of actions and purpose that, to your point, can be addressed by changing the stimuli? I do not mean to sound glib; I recognize that nothing is just that simple. But I've never heard of depression spoken about before through the lens of narcissism or self-centeredness. Worth exploring?
I've encountered a few attempts at evolutionary explanation, but none of them were exactly elegant. The best one argued that it was a sort of risk-minimizing hibernation; if the world is (or seems) randomly harsh, if effort seems uncoupled from reward, then it makes sense to sleep a lot, not attempt new things, and eat calorie-dense food. That may be part of it, but I tend to think there's much more going on here, and some of it may not be even vaguely adaptive.
Regarding psilocybin for depression: when I've looked this up, all the writeups I find are on this one study from November 2020:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772630
"In this randomized clinical trial of 24 participants with major depressive disorder, participants who received immediate psilocybin-assisted therapy compared with delayed treatment showed improvement in blinded clinician rater–assessed depression severity and in self-reported secondary outcomes through the 1-month follow-up."
It does sound promising, but the facts that 1) it's one very recent study, with 2) a sample size of 24, and 3) only *one month* follow up give me some pause. Is anyone aware of other research on psilocybin for depression? Is there any reason to believe that this apparent ameliorative effect for one month would continue (or not)?
The paragraph beginning “In a study in India” has a duplicated comma and what feels like too long of a link to me? It’s hard to distinguish that link with the subsequent link to an iron supplement - I would make the link attach only to the word “study” at the beginning.
Unrelated, but I also wonder if more pictures in this writeup would be advantageous - you're optimizing for readability within a population not known for its dedication to reading thousands of words of technical information, and while it's more readable than anything *else* I've seen on depression, I don't think it would hurt to push a little harder on the "low effort to read through" side of things.
The thing with images is that they only help if you use them to illustrate the idea or showcase something.
It's easy to insert random vaguely related pictures you've found on google into any text, but that's rarely a good thing to do.
I think Scott is right in avoiding illustrations here, because it's hard to add any meaningful images when the topic is so abstract, and you don't want to dilute the message with random noise (irrelevant pictures). Which might be even more relevant if we talk about people with decreased attention.
I could see a case for mildly ornamental section dividers just to add a little visual interest.
This paragraph was the first paragraph I could not easily understand.
Along with the neurological, biochemical, and cognitive levels mentioned above, there’s a fourth level on which you can try to understand depression – a mathematical level. On the mathematical level, depression is an attractor state in a dynamical system. It looks like that dynamical system takes both life events and biochemical factors as inputs, and based on the different weights of the edges of the graph in different people (probably at least partly genetically determined), either or both of those can shift it into the new depressed attractor state.
I don’t know what an attractor state is, and how it relates to “weights of the edges of the graph.” You may want to translate this paragraph into layman’s terms.
This is best read after https://lorienpsych.com/2020/11/11/ontology-of-psychiatric-conditions-dynamic-systems/ .
Which is a problem, if you're just someone who wants to know if you're depressed and what to do about it.
That was the paragraph that made me do a "whut" and on the same words, too.
PS. Spooky retraction at a distance: your Lorien link on light therapy cites https://osf.io/8ev4u/ , which has been retracted for a painfully stupid reason. The up to date link seems to be http://sci-hub.se/https://doi.org/10.1177%2F1745691620950690 . Here's hoping the conclusions didn't change in peer review...
Some random comments below. Overall, shorter paragraphs would be good. Walls of text are hard for someone who is depressed. Seems like this may be trying to do too many things at once -- I wonder if a more spare structure with links to side subjects might be better. The level of generality varies a lot which makes it a bit unclear to me who you see the main target audience to be. It's clearly more than just potential patients, but for people beyond potential patients, it seems maybe too specific about dosages and supplements/meds in a way that strikes me as risky.
Some of the details are lovely -- like the Levitt study.
Okay, some specific points, take or leave, for what they're worth:
* Section 2, para 2 "so nobody should feel obligated to try any modality that doesn’t feel like a good fit for them" -- I think reluctance to try things is a big barrier to treatment. People are terrified that something new will make them feel worse and that they can't risk that. So I think people ought to be encouraged to TRY things and that only by trying things will they learn what might be a good fit. There are so many people out there who say "Oh I hate antidepressants" who have never taken them or "I know therapy won't work for me" who have never tried. We are incredibly wrong sometimes about what we think we know and are so good at making excuses when we're afraid. We want to encourage people to take some risks in order to get treatment while their depression is likely to make them extremely, paralytically risk-averse.
* Stress isn't mentioned anywhere in here that I saw. Stress is sometimes a really big factor in depression. You mention situational things like bad jobs or relationships. It might be good to mention that long stretches of elevated stress can produce depression as a result, and that stress-reduction may be an important part of treating depression for some people.
* Women and hormones. I had two cases just this week of women who were on different forms of hormonal birth control who upon discontinuing (or changing) saw all their depressive symptoms resolve after years of suffering needlessly -- these stories are widespread. Hormones mediate mood for women a great deal. I know for men as well, though differently. Worth a shout-out somewhere. You could include where you mention thyroid and anemia or separate para. Research I saw said HRT is more effective for depression in perimenopausal women than any kind of antidepressant -- and yet doctors are still not acting like that's the case. Women are perimenopausal for like a decade of their lives and are routinely put on SSRIs during that time for mood issues. And side note: I still meet psychiatrists who don't realize that you can treat PMDD by doing SSRIs for last part of cycle only.
* Lots of depressed people I've known/worked with were surprised how much their physical pain turned out to be part of their depression. Some mention of that might be helpful. You mention in passing re: Duloxetine, but might be good to say somewhere up top related to symptoms of depression itself.
* I know a number of psychiatrists and psychotherapists using psilocybin-assisted psychotherapy. Is it right to just say that psilocybin is illegal?
* I've recommended L-methylfolate to a ton of people and many people have reported benefit well below 7-15 mg. It seems a bit definite to me to recommend the max dose if you're going to be mentioning specific dosages in here at all. I encourage people to find min. effective dose in everything because people metabolize all these somewhat differently. You could cut part about MTHFR because people who don't know about it won't care and people who do won't gain anything from your mentioning it (I would edit out mention of more things like this in there, not central to what you need to convey). I agree it doesn't need to be factored in.
* Do you think it's worth mentioning neurofeedback? Defer to your research. Have seen some good results for depression (and trauma and anxiety and insomnia).
* Surprised you recommend Wellbutrin as the first-line since anxiety is so often also an issue and people may respond badly. OTOH, I like that you do because it's under-recommended. But then this raises for me why you want to lay out these specific regimens anyway -- if readers are going to be your patients, they're going to get your best judgment for their situation. If they're going somewhere else for a prescription, they're not going to get Wellbutrin because they read about it on your website. I think you could make the regimens more general and thus simpler.
* None of the regimens say "see a therapist." Which seems inconsistent after pointing out that combo meds AND therapy are the most effective.
* There seems to be some equivocation between 5-HTP and SAM-e and then you end up recommending 5-HTP mainly. Not sure the logic there. I've had equally mixed and good experience from people with both. 5-HTP game changer for some, totally ineffective for others, and made some people VERY anxious. SAM-e seems to produce less love/hate reactions in my experience. Don't see a reason to recommend one over another, but your experience may say different. All the supplements are a bit of a black hole unless you want to address in a separate article. The only one I feel like is a no-brainer for people to try is L-methylfolate.
* I guess I take issue with recommending behavioral activation above all other forms of psychotherapy. Many psychiatrists say to their patients, "if you're going to go see a therapist, at least make sure they do CBT." That one doesn't offend me quite as much as a narrow focus on behavioral activation. It's also going to be harder for people to find a therapist by saying "I want someone who will do behavioral activation." There's decent research that the outcomes for intensive short-term dynamic psychotherapy were more durable and just as effective as CBT. People with long-standing, recurring depression are going to need something more comprehensive than behavioral activation. In any case, I don't see a reason to single that modality out from the point of view of the person seeking therapy particularly when we don't know what's going on with that reader's particular depression.
Addendum to the comment on women and hormones - I have noticed that HRT, and specifically oestrogen supplementation, has been the salvation of several middle aged women in my social group. It seems to have a powerful effect on both long-term mood and physical function.
I'm surprised by the advice not to listen to "sad music" when depressed. Does the psychiatric community not view catharsis as legitimate or useful? When I'm down I'm going to be more in the mood for Leonard Cohen or the blues or Schoenberg. It seems to make me feel better. A sign that I'm really down is when I'm not in the mood for music at all. That's more like staying in the dark bedroom. Good, "sad" music seems to work a lot like hearing a good cynical joke. Perhaps it's a "misery loves company" effect. Music that fits your mood can be good company.
Or perhaps it is analogous to what you say about exercise: perhaps it would be better to listen to more energetic, "happy" music if you can stand it, but that's more like a vigorous workout, whereas listening to "sad" music can be more like a walk that at least gets you outside.
Disclaimer: Pro: I'm a Psychiatry resident. Con: I'm a psychiatry Resident
I feel this guide (and modern psychiatry for that matter) does a major disservice by grouping all of depression into 1 category. In the beginning, you mention it has biological, psychological, and social causes... but you don't mention that there's biological depression, psychological depression, etc... and that these are completely different entities with completely different treatment modalities. I think you can still leave everything grouped, but consider giving more credence in the beginning to the fact that a 50-year-old man with catatonic depression has a categorically different disease from the "really depressed" 16-year-old girl who "just can't" while sipping on her mocha latte.
Also... I would consider removing from "The short version" recommending reading David Burns' book (or any book for that matter, especially one you haven't read). I personally think it severely minimizes how complicated the psychological cause is for psychiatry. I'm one of those weirdos who likes psychoanalytics, and think Depressive personality disorder should be more widely recognized. The thought of someone with a personality disorder reading a book with the intention of fixing their "psychological depression" makes me hurt inside.
There's a now-defunct blog, The Fugitive Psychiatrist. He wrote a long post on anti-depressants and it's essentially a guide to depression. I think he did a really sublime job, I would consider checking it out: https://web.archive.org/web/20190803223834/https://fugitivepsychiatrist.com/antidepressant-guide/
I agree about not recommending Burns' book specifically. I've recommended that book among other to lots of people and have gotten better feedback from things that are either more workbook-y (like DBT or ACT workbooks that have lots of exercises) or things that are more compassion-based (like Kristen Neff et al).
That link to the fugitive psychiatrist is a good one, thanks. I liked the whole description of "the hill" and that everybody has a hill.
I also liked this: "Psychotherapy also has the added benefit of providing long-term relapse prevention (1). You could attempt to prevent relapse by cycling though antidepressants for the rest of your life, but after your second go at paroxetine you’ll see why this isn’t the best strategy."
Even if lifestyle and cognitive habit changes alone don't get someone out of a major depressive episode (sometimes they do, not always), they are often an important part of preventing relapse back into one.
In section 2.1, you might consider that "getting away from the depressing thing" is only useful advice if a person is depressed by outside circumstances. (Or has the financial wherewithal to change their current work/life situation.) People suffering from depression brought on by internal things like PTSD, body dysmorphia, or internalized self-worth issues are more likely to see themselves as the problem. And if you are the problem then the fastest, most effective, and permanent route to "get away" is suicide.
Obviously, that's not what you're suggesting, but it is the worst possible way that section could be read. And your target audience is primed to read things in the worst possible way.
This is a good rough draft, but the people you want to help are going to have a lot of heavy triggers and you should consider having someone read it through for those.
With apologies, an objection on your diet advice:
As an anxious person who cooks a lot, I have always found injunctions against "processed food" deeply panic-inducing because I have no idea which of the things I do in my kitchen are "processing" and the underlying studies tend to be based on unhelpful or weirdly demanding (eg, Siga says that flour is an "unprocessed" food, baked bread is "processed", and sliced bread is "ultraprocessed"; who knew my hands and knife were so powerful!) or inconsistent (NOVA says "extrusion" is ultraprocessing, but pasta "unprocessed" despite being made by extrusion?) and seem to assume that nobody ever prepares their own food.
And that's without even starting on fermentation.
So if you are going to ask an anxious person to avoid processed food, please do them the service of telling them what "processing" is in the context that you intend, or check that the studies you are relying on use the same definition of process and of UPF. There is after all no need to drive us any crazier than we already are.
As a nonanxious person, i generally interpret "processed" as anything that you dont cook yourself. Companies that perform complicated recipes in factory, like bread or cake or processed tend to put in lots of obscure chemicals, maybe a color or flavor enhancer, anti spoiling agents, something for flavor or smell. Many of these chemicals have unknown (possibly no) effects on human health. Raw products like flour, fruits and veggies, etc tend to have fewer such alterations. So theyre "unprocessed".
Yes, I would take the stuff about bread to mean that if you *buy* a pre-made loaf of bread, that's processed, and if you *buy* pre-sliced bread in a plastic bag from the supermarket, that's ultra-processed (because it usually contains a lot of additives which are needed to keep it fresh when it's already sliced and has a lot of cut surface area). If you bake bread at home and then slice it, that's unprocessed. I'm sure they're not expecting anyone to eat raw flour.
But I agree the terminology is confusing, and it would be helpful for Scott to clarify briefly when he refers to it.
(Similar issue with "fried food". I assume it means fries from McDonald's or deep-fried battered fish from the chippy - not fresh vegetables and salmon that I shallow-fry myself in a little bit of olive oil or coconut oil. But the terminology is confusing.)
I also got really concerned about "fried." If I broil a burger it's okay, but if I finish it off in the cast-iron, it's bad?
And a limit of "three per week" for processed foods could be an impossible task for lots of people. I almost got anxious thinking that I might be hitting that right now, with an overall healthy diet full of vegetables and things that I cook myself. People who don't have the skills or tools to cook meals for themselves need some firmer/easier [1] guidance.
"Replace soda with water," on the other hand, is a feat anyone can do.
[1] Yes, that sounds like a contradiction. But by "firmer" I mean "more concrete steps for how to remove more of these things from your diet." By "easier" I mean "things that can be accomplished."
"I also got really concerned about "fried." If I broil a burger it's okay, but if I finish it off in the cast-iron, it's bad?"
I think the question with fried food is things like "do you use a lot of oil/animal fats when cooking, are you cooking very fatty foods, are you deep-frying a lot of foods?"
If you're cooking burgers, depends how fat the mince meat is, generally I find there's enough fat in the meat naturally not to need more added when shallow frying. If a lot of fat runs off as I'm frying, I'll either spoon that out of the pan and dispose of it, or (for example) remove the sausages etc. and dry them on kitchen paper while I fry eggs in the fat.
"Not too much fried food, the food not with a lot of fat in it before frying, cut down on the added fat as much as possible" is the reasonable way to approach it. If you're roasting meat, you need and want a level of fat in/on the meat so that it won't dry out while cooking. If frying, you don't need as much fat. If the meat or fish is very lean, use a little bit of vegetable oil to cook it.
I think a lot of the difficulty is around "process" being a verb but the actual plausible subject of most of the studies being nouns -- ingredients in the food -- rather than the actual, er, process of making it.
It seems like the word "processed" some times means a list of ingredients rather than any particular act of processing -- or even some times an attempt to not actually just list the ingredients, so as to keep me guessing (is my pickling salt evil? yeast extract?).
Which means when I'm feeling tired, sad, and unmotivated to cook, there's yet another voice in the kitchen telling me I'm not worthy of cooking because the hand blender is going to give my family processed cancer. Because anxiety brain is a cruel evil liar.
That is just way too extreme, IMO. You can get lots of fresh bread from bakeries, and even from Ralph's (or equivalent), without any kind of preservation agents. Yes, if you buy pre-sliced bread in a plastic bag, it likely won't taste nearly as good, but no one is forcing you to do that (other than lack of funds, admittedly).
That said, someone does expect you to eat raw flour, or something close to it :-)
https://en.wikipedia.org/wiki/Matzo
It's hard to do because it's not cut and dry, but the meaning is still there. In general, when factories "process" things, they tend to make the thing more consumable and you eat more of it. Slicing bread makes it more consumable, and, presumably, you may consume more of it.
Because the bread was processed to make it more consumable, in the steps of processing, they could have added other things, that also make it more consumable. Sugar. Preservatives.
In general, (and this is a broad rule of thumb) the more processed the ingredients are before you touch them, the unhealthier the food is, and the more likely you are to overeat.
It makes sense, if you think about it. Companies are incentivized to make things as consumable as possible. Unhealthy food is often more consumable. That's why things in America are considered both very commercialized, and very sugary/delicious/obesity inducing.
So, we don't need to know the EXACT reason why, but when comparing two foods, let's say, guacamole pre-made in single size containers, guacomole pre-made in a large container, and a guacamole kit that comes with 3 ingredients, and an avacado, they go from most processed to least processed. It's possible the ingredients and nutrition and portions COULD be the same in each step, but just the matter of portioning, or what ingredients you choose, or a bevy of other hidden things (salt added, preservatives, enriching, etc) make it not that processed diet.
By trying to eat how Scott is suggesting, I'd recommend trying to start from base ingredients more often. It will feel healthier in a lot of ways. At least begin by starting less processed. Maybe you don't make your own naan, but you make your own hummus. Maybe you stop buying premade salads and start buying heads of lettuce. etc.
Not something I had considered but you are correct, for anxious and/or scrupulous people this kind of blanket phrasing can be very confusing and worrying.
Okay, generally take it that by "processed food", what is meant is factory-made products high in sugars, salt, filler starches, and other bulking agents. Some may or may not have artificial flavouring, artificial colouring, artificial sweeteners.
Some processed foods will have a lot of fibre/roughage removed. This is where it gets tricky, because frozen vegetables? Nearly as good as buying raw, whole vegetables and much easier if someone is depressed and suffering from lack of energy/motivation, so that cooking with frozen veggies is easier than the task of buying, washing, peeling, chopping etc. whole vegetables. Processed peas in a tin packed with sugar and salt? Not so great. But again, if it's a choice between "peas from a tin" or "no vegetables", then half a loaf is better than no bread. Processed foods as in "ready-prepared carrots in a bag"? Great, they've only been washed and chopped so you don't have to do that.
Speaking of bread, yeah, carbs are The Devil (I am trying to diet, every diet recommends cutting out carbs, guess what I love - yes, bread and spuds). Processed bread = white bleached flour with improving agents and full of air. Not everybody is going to home bake their own bread, so while you needn't break the bank on buying artisan bread, try to go for wholemeal or breads that are fortified.
> As an anxious person who cooks a lot, I have always found injunctions against "processed food" deeply panic-inducing because I have no idea which of the things I do in my kitchen are "processing" and the underlying studies tend to be based on unhelpful or weirdly demanding
Good point. Clearly "unprocessed" foods are those that are or can be eaten in their raw form, like lettuce and fruit. Every other form of food is processed to some degree, so the question is only what the processing introduces or removes from your food.
Some foods can't be eaten or digested at all without processing, and processing makes their calories more accessible, like flour. The cooking process can also make food safe to eat. Clearly some processing is beneficial, because calories matter most of all to survival, but processing can also reduce the nutrient content of food. For instance, boiling or peeling can remove nutrients from vegetables that may be in the skin. Nutrients are less important than calories, but still important.
On more extreme ends of processing, are foods that are wholely synthesized, like candies and artificial flavourings. These are generally considered unhealthy because even if they contain calories, they rarely contain essential nutrients.
In this category are also foods that add ingredients so they taste better or addictive (to some people), like adding too much sugar or salt.
So processed food is not necessarily bad, just have it in moderation and preference less processed food, if you can afford it. If you're financially less well off, processed food can often get you more calories per dollar spent, but you might be short on nutrients.
Let's break it down to the specific things that food manufacturers do that make our food less healthy.
1. adding lots of high fructose corn syrup to everything: this adds nutritionless calories and makes you fat since you have to eat more food to get the same amount of micronutrients. Hunger is sometimes affected by micronutrient statuses, for obvious evolutionary reasons. HFCS also makes the food taste better, so you eat more of it.
2. adding nitrites to cold cuts: nitrite is a strong oxidizer. What could possibly go wrong? Studies have linked it to DNA damage and colon cancer. Beware celery concentrate is a synonym for nitrite.
3. Adding lots of high-PUFA vegetable oils to everything. Most people already consume too many omega-6 PUFAs. Plus PUFAs are unstable at high temperatures and not appropriate for frying or high-temperature baking. They turn into trans fats and other bad things. [all fast food joints fry with high-PUFA vegetable oils anyway because they're cheaper than coconut oil or tallow. Hence the ubiquitous advice to avoid all fried foods. But maybe it's not frying per se, but the breakdown of PUFAs at high temperatures. Tallow fries are tastier and healthier]
4. adding lots of preservatives to everything:
(speculation, not aware of any study testing this) excessive preservatives might kill some of your intestinal flora, leading to worse digestion and downstream effects on weight and immune function. McDonalds food always aggravated my IBD, and I blame it on that. It is probably better to eat food that has been preserved by freezing rather than food that has been preserved by biocidal chemicals.
I would not mention ECT in the first paragraph. It makes the topic seem scary, and ECT is rarely used anyways.
I think one of the main contributors to depression that is possible to solve but hard to solve, is an unhealthy living situation. Living with an abusive household member, working a dead-end job or a job you hate, living in an expensive area with no hope of upward mobility, living in a gloomy place if you have SAD. All of these contributors have a solution, but the solution requires a big change in the patient's life. Often treating the symptoms is all that can be done, but sometimes the cure is removing the big problem in your life. These solutions are more social work than psychiatry. Even if you are not equipped to help apply them you could assemble a roster of helpful resources for your patients.
Maybe your patient profile is more in line with the person who has a great life yet thinks they are a failure because of a biological condition. But many people are depressed because they have bad life situations. It would be a great thing to help even a few.
>On the cognitive level, depression is a global prior on negative stimuli.
Unless your entire patient body is Bayesian thinkers, I would recommend finding a different way to state this.
That statement was immediately followed by an explanation of this idea:
> A prior is like an assumption, bias, or context, in the sense “you have to take that in context”. Your brain is constantly applying priors to all its perceptions to try to wring as much extra meaning out of them as possible – you can see some examples here [link to summary of "Surfing Uncertainty"]. A global prior on negative stimuli means that the brain interprets everything it sees in the context of an assumption that it’s probably bad.
I would expect that readers who read the explanation, & perhaps read the linked article, would understand this idea.
> Most studies that found supplementation helped got effects only from very high doses (around 2 g daily), more than you could realistically get from capsules – so if you are supplementing for this purpose you should consider liquid oil.
I have 2000mg fish oil capsules right here (though admittedly they are quite big). Looking at the ingredients just now, I see, however, that it's only 700mg Omega-3 fatty acids and the rest is, I guess, other kinds of oils, so maybe I should buy other capsules.
I loved this article and very much wish it had existed when I was a depressed 19 year old so I could have read it then (I'm 34).
I don't have a critique of what is written, but I think there's a very very very important section you need to add. You talk in 2.6 (and mention earlier) that before treating depression one needs to figure out if he is bipolar, or if the depression is caused by insomnia, etc. This is all great and true, but would be VERY USEFUL which is not provided here or by any other depression resource I've seen is ***how to tell if you're depressed or ___________***. A thing that could go a long way here is some simple scripts for how to talk to a healthcare provider about these distinctions, in a way that is useful to the clinician.
When I've struggled with depression, one of my biggest hurdles has often been wondering, "am I actually depressed, or am I just an under-achieving fuckup who is looking for an excuse to rationalize my under-achieving?" Similarly, I have read lots and lots of things and am still not really sure if I'm just depressed or have anxiety or am bipolar or a regular insomniac or have circadian rhythm disorder or ADHD (I think ADHD needs to be brought up at SOME point in this post because the ADHD --> overwhelmed --> failure --> depression pipeline is common, but also lots of ppl think they have ADHD and don't).
For a personal example: in Jan/feb 2020 I couldn't sleep at all, sometimes staying up 60 hours in a row, in hindsight I was definitely hypomanic, but that is the only time I can remember being any degree of manic. Am I bipolar? Or did I just have a million stressors (new job/new city/breakup/chronic back and stomach pain that was aggravated by the stress) and how should I know? What's the most productive way to talk to a clinician about it, because even though it's totally irrational, I'm convinced a doctor won't believe I have real problems because objectively I shouldn't so I must be faking?
Even within the classic symptoms if depression list it's like:
1a/b) is my low mood because of depression or because fucking Donald Trump is president and everyone seems to be in a low mood? Am I anhedonic or is there just nothing to feel good about, like objectively?
2) I have always had trouble getting to sleep, but I don't think I've always been depressed? Am I "depressed" because I'm not sleeping extra badly right now because of a constellation of outside forces or because I actually suffer from depression? How would I know?
3) loss of interest in activities: well I've never really been one for hobbies, and my interest in video games/reading books/watching tv/scrolling Twitter has always waxed and waned. Am I losing interest in activities, or have I just not found the right game/book/show/etc
4) Guilt: how do I know when I'm feeling a correct amount of guilt vs a depression amount? I try to be a decent person, but there are times I have treated people I care about poorly that I'm right to feel guilty about, how do I know if it's a symptom of depression or a functional moral compass? Everybody gets random memories of times they were embarrassed as youngsters and we talk about that as a cultural phenomenon, but other people get that about guilt, right? It's not just me, right?
5) lack of energy: is it because I've been having trouble sleeping or because of depression? Is it because I'm in my 30's now and I just have less energy, it l or depression? Is it because my job is demanding or is it depression? You know? Am I just whining about things everyone feels, or am I uniquely tired in an important way?
6) Concentration problems. So this is a personal one for me. I was a classic, "gets almost all A's, 99th percentile on every standardized test I ever took, never does homework or studies, was fine graduating 9th in his class instead of first" type of under-achiever (I also went to a very poor public high school). I always wondered if I had ADHD because my best friend did, and it seemed like our brains worked the same, and when I'd read things by ADHD people about their disorder it felt familiar, and in college I used buddies in a frat to get black market adderall and I studied much better on that. BUT: maybe school is just boring and everyone functions better on stimulants? And I worried my doctor(s) would think I was just bullshitting to get access to Adderall if I brought it up.
7) appetite problems: so many things affect appetite, it feels hard to pin it to any particular source
8) <skipping>
9) suicidal thoughts: every millennial I know "jokes" about wanting to die, when I think that is it a sign of depression or just how my generation articulates stress?
Anyway, this comment has gone on long enough, I hope you find something useful in it
Addendum: I know it's a tricky legal area for you, but the fact that you don't address Marijuana as treatment for anxiety/depression (whether you think it's total bullshit or not) is probably the biggest hole in the piece
Seconded, and I'd also be interested to hear about CBD in this context.
Here are some things i have experienced that in hindsight were for me indicators I was severely depressed that I think may be relatable to others:
1) feeling lonely, scrolling through my entire contacts list, and about every person thinking, "they don't want to hear from me, I'll just bum them out"
2) thinking about brushing my teeth for the first time in two days and then deciding, "fuck it, it doesn't matter"
3) spending every waking moment both playing a video game AND listening to a podcast or tv show I've seen before so I don't have to think about my life in any way whatsoever (note: this rationale was only clear in hindsight)
4) not drinking water (this one sounds stupid but when not-depressed I drink lots of water)
There are more I'm sure
"2) thinking about brushing my teeth for the first time in two days and then deciding, "fuck it, it doesn't matter"
Yes! That is one of the strange things about it, the way it just leaches away energy and ability to do things. Objectively, you know you should brush your teeth, it'll only take a couple of minutes, what is the problem? But the very thought of standing at the sink and getting the toothpaste and - ugh, leave it, too much work.
Sitting in place for twenty minutes trying to persuade yourself to do some small necessary task that will only take a couple of minutes and being unable to get up and do it.
That's why the advice about "just get up! just go for a walk! just start eating healthy!" - you *know* it's good advice, you *know* it will help, but taking even one step? It's like asking you to fly to the Moon by flapping your arms.
I have no idea how much of this might apply to other people, but have a data point.
This is reminding me of the time I read Oliver Sacks' book about Parkinson's, and it seemed to me that my difficulty with taking action was like a mild version of what they had. (I didn't think I had Parkinson's.)
It seemed like the right course was to learn enough neurology so I could do something about it.
Weirdly, even though I couldn't get myself to study neurology and even though I thought there might be a physical basis, I became a lot harder on myself about having difficulty with taking action.
I told a friend about this, and she spent 15 minutes telling me I was a good person. No specifics, as I recall, just the generalization about being a good person.
The difficulty with taking action lifted for about two weeks.
No need to give more info here obviously, but I would be curious if you find it clarifying taking the HAM-D assessment Scott links to or you can also find a PHQ-9 free online and see how you score (https://patient.info/doctor/patient-health-questionnaire-phq-9).
These assessments aren't god or replacement for a good clinical interview, but they can cut through some of the circular questioning that people can find themselves in when they are depressed. If you take them across time over some weeks or months, you can also get a feel for your own ups and downs, and it can help provide a somewhat more objective perspective out of one's subjective experience.
One of the trickiest things about depression is that it does often manifest as a very loud inner critic who then tells us we're "just whining" or that we deserve to feel guilty or whatever. Depression creates a really big distortion field in our perceptions and thoughts that while isn't full-blown psychosis, is nonetheless very very hard to see outside of. From inside the depression, the volume of the inner critic doesn't seem like a manifestation of depression but rather The Truth about us or The Truth about the awfulness of the world. If we're pretty identified with that inner critic anyway, it's going to make it that much harder.
Right, so everything you said here is 100% correct, and thanks to some combination of SNRIs, lifestyle changes, and "who TF knows" I've been pretty okay since late 2020, I was just giving feedback on what I thought would have been most helpful for me (I am not representative of depressed people generally, obv) when I was very depressed/anxious and casting about the internet for ideas