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
Also, I have taken this questionnaire when very depressed and even though I scored very highly I
1) did not believe in the validity of the questionnaire (despite the fact of clinical evidence of its legitimacy)
2) thought the answers were so transparent it would be impossible for a doctor to actually believe me, because if a person just wanted a diagnosis of depression (I have no idea why a non-depressed person would nefariously want this? Depression makes you worry about very stupid things) it was super clear what answers to give
3) I did not (and honestly still even while not depressed do not) trust my short term memory or sense of self enough to be confident in my answers
I know you touch on this, but I think it would be very helpful if you called out more explicitly the fact that therapy *doesn't* work for everyone, and it's fine if you hate it and want to persue medications.
I have had extremely negative experiences with therapy (maybe because I didn't go enough times? Maybe because my particular therapists are a bad match? Maybe because I'm an intellectual jerk? Maybe because I have a hard time trusting people I haven't known for a very long time? Maybe because I'm the baby of my extended family so I'm irrationally sensitive to feeling like I'm being condescended to and the nature of therapy is that it's a credentialed person telling you to do obvious things that sound obvious but are difficult to do).
But the way our culture talks about therapy it made me feel like a failure or like there was something fundamentally unfixable and wrong with me because I didn't like it. Or that I was just being a stupid-coward-quitter because I hated therapy and everyone else on earth apparently loves it
Yeah, I don't like that either, that notion that someone is deficient in some way because they didn't find therapy helpful. Also, there are an awful lot of not-so-great therapists out there.
I'm interested in whether the people who don't find therapy helpful or don't want to try therapy DO get benefit from the kind of apps or workbooks that are shown to be effective. Because that would suggest that the *skills* that one gets in therapy are effective but that the relational mode of delivery by a therapist serves as a kind of barrier. Some of the benefits of therapy are entirely relational, but some of them are learning skills, and it makes sense to me some people benefit from the skills but not from the relational part, which for them interferes with getting the skills.
Therapy is rarely described well (I think.) For people who are not accustomed to getting angry the tendency to stifle that will work against projecting the problem onto the therapist and solving it by proxy. For people who are too used to getting angry it will also work against the proxy solution. If not a problem proxy solution, therapy is a source of companionship and/or good advice, which both work against the proxy solution. There should be more ways to gain mental health skills. I don’t think I ever did CBT correctly. The times I approached correct I did not trust the therapist enough to inhabit the frustration/anger toward them. Your general remove/mistrust might indeed make traditional therapy turn into feeling like trying to find ways to piss you off! Probably hating it was exactly right, then you are expected to have the skill set for explaining your frustration to the therapist and the interest in doing so, then the therapist is supposed to notice you are doing that and respond in such a way that your relationship is deepened by the honesty rather than weakened.
The “guided confessional” therapy can be relieving but I think it might not be therapy per se.
I agree though. People sign up for therapy thinking it’s like finding an honest friend when it might not be that at all.
A therapist asked me, "do you think you deserve to be happy?" And my reaction was:
1) it's really annoying and condescending to ask me a question everyone on earth has agreed there is only one acceptable answer to. If you want an exchange this empty, email me a script, don't pretend to be asking me a question.
2) the premise of this question is stupid as people rarely get what they, "deserve" in life.
Another time a therapist literally told me, "it sounds like you know all the things you're supposed to do, you're just not doing them" and I was like, "yes no shit the solutions are very easy, it's the doing them that is hard" and got no productive advice from there.
But the absolute single worst therapy thing that they apparently drill into everyone's heads in "therapy 101" is the fucking, "keep a journal/log/list of everything you do for yourself no matter what it is, it could be brushing your teeth, taking a shower, etc to, 'build some positive momentum'"
1) if you have ever been severely depressed you will know that even if you gave this an earnest effort you will have days where all you can put is like, "drank glass of water" because you didn't even brush your teeth and just ordered garbage delivery food, and looking at that shit will make you feel a million times worse about yourself
2) I have never ever ever successfully been able to keep a journal on any subject for more than 2 consecutive days at any point in my life no matter how depressed or mentally healthy I was at the time. Asking me to journal all my activities, for an entire week, while I'm depressed feels roughly like a therapist saying, "okay, I'm going to give you a really easy depression fighting strategy that works for almost everyone: all you have to do is climb Mt. Kilimanjaro. Every week. For 6 months.
3) related to #2, the I'm just not gonna do the journal thing, maybe it's an ADHD/executive dysfunction thing. So all the assignment accomplishes is giving me another thing to feel guilty about and making it more likely I skip my next appointment because I don't want to deal with telling the therapist I didn't do my fucking homework.
Also like, my problems have never been particularly mysterious, and all the normal advice works totally fine, the issue when I'm depressed is I can't get myself to do any of the obvious things that work no matter how hard I try. IDK how I expect therapy to help me do the obvious things that work, but I am not convinced someone telling me, "you should do the obvious things that work" is more effective than a book telling me, "you should do obvious things that work."
At least with the book I can stip the part about the damn journal.
Good therapy should always be working with you to help figure out how you can start to do something that may help. It HAS to be individualized; journalling is not for everyone, NOTHING is for everyone. And re-calibrating every time what we've figured out to try doesn't work. W/o shame or blame.
OTH, when I've been doing that with a patient for multiple months and we're really getting nowhere, I make them go back to their MD to re-check all the physical stuff that might be causing or sustaining the depression, and then check all the rare stuff that might. And we consider meds or different types of meds.
meds have worked great for me, and thanks to an SNRI & a low dose of extended release adderall I feel like I have a good handle on my depression for the first time in ages. Obviously therapy is great and helps lots of people, but the way it gets talked about in popular culture really chafes me I guess.
I'm glad to hear you have found things that are working for you. Thanks for your post, made me grin. I think the world needs more honesty about experiences of therapy. How did you manage to get an SNRI? Did the doc suggest it or did you extract it out of them?
"A therapist asked me, "do you think you deserve to be happy?"
My goodness, everything you describe resonates so much with me! My answer to that would be "Well, I know the answer I'm *supposed* to give, i.e. 'Everyone deserves to be happy', and I even know the answer under the answer I'm *supposed* to give; viz, I say tearfully 'no, I don't deserve to be happy!' and then you fill me up with platitudes about why yes I do deserve to be happy because that is supposed to be the root of my problem - I don't feel deserving, but let's skip the bullshit.
No, I don't *deserve* to be happy. Nobody *deserves* to be happy. It's like grace: you can't earn it, you can't do a ton of good works, you can't keep a running list of "Why I've Been The Goodest Boy (or Girl)" in order to prove that you should get the Hollywood Happy Ending.
(People don't deserve to suffer, either, but sometimes they make choices for whatever reason that end in suffering, and you can forecast this - why else all the "don't smoke, don't drink, lose weight, exercise" advice trotted out by the medical profession?)
This is why the scene from "The West Wing" where President Bartlett does his 'non serviam' speech in front of a crucifix is full of shit. I'll give Aaron Sorkin a break, but Martin Sheen is Catholic, he should have known better. Bartlett trots out his "I've been The Goodest Boy for so long, I don't deserve bad things to happen to me" whinging in front of the crucified Christ, the prime Christian example of someone who Did Not Deserve This? Put it away, Jed, you had the seven fat years now welcome to the seven lean ones.
So being a Good Person doesn't mean I'll be happy. I can't work my way to happiness. Maybe winning the €10 million lottery will make me happy - or maybe it won't. There is no "deserving", there just is the reality of the world we live in: our biology, our environment, our circumstances, the people around us, natural and unnatural disasters, learning skills to cope with all the above."
Ditto the part with the journal: I have never been able to keep a diary, either, and whenever I've had to do one for school assignments or so forth, I end up writing a work of fiction to pretend I did all these interesting things because otherwise it would read *every single day* "Got up, went to school, came home, did my homework". And precisely as you say, the point about 'building positive momentum' where the therapist then goes "Well done, you brushed your teeth every day!" oh great, another thing to feel guilty about: this is something easy normal people do every single day and you, worthless loser, can't even manage this much?
Today is my birthday. Today is also when the depression, or mood swings, or whatever, kicked in for no particular reason (no, it being my birthday didn't trigger it, it's not A Significant Milestone, it's just like every other birthday in my entire life).
So I've ended up dumping the birthday cake and the flowers family members sent me into the bin. I've asked not to get any more such items. I want to get blind drunk. I also want to go back to bed (it's currently 2:30 p.m. over here) and go back to sleep for at least the next eight hours. Being alive hurts and I want it to end. (I can even pinpoint the location: at the very top of my breast bone. It hurts). I'm not going to self-harm (though I do sort of want to get a scissors or a knife and start scraping at my arm) and I'm not going to kill myself. I would, right now, really really like if I did go to sleep and never woke up again. I don't have any sedatives, hypnotics, or other medication, so don't worry there. I may get drunk enough to help fall deeply asleep. Maybe not, dunno.
Writing all that down in a journal under "Didn't do any of the housework I planned to do. Did get up to destroy stuff" is not going to help with "positive momentum". Talking to people is not an option because it will not help. Nothing helps except to wait it out.
Eventually it will pass. Eventually it will come back again. So it goes.
Overall this is excellent & I expect it will help me try to get treatment for my depression. Several comments:
⋅ I found a meta-analysis of controlled trials of therapies for self-control/self-motivation/mental 'energy' in particular at http://www.devcogneuro.com/Publications/J_of_DevCogNeuro_paper_in_press_2016.pdf , which concluded that there was little evidence that physical exercise by itself improved these & that improvements reported from some forms of exercise such as sports & martial arts were probably due to the mental component of the activities. Does this mean that exercise mainly helps with other aspects of depression than this, or that additional evidence that that study didn't consider contradicts its conclusions, or are they just studying something different?
⋅ In https://slatestarcodex.com/2014/06/16/things-that-sometimes-help-if-youre-depressed/ you recommended modafinil to treat some of the symptoms of depression, & based on what you've written here, if it works, I would expect it to improve self-confidence like behavioral activation does. However, I see that you have omitted it from this. Do you still think it is likely to help?
⋅ I agree with the other comments here that "Realistically, most people know if they’re depressed or not" is not always true. My depression began with anhedonia & problems with concentration & motivation, so I interpreted it as akrasia, followed by sadness about the effects of akrasia, rather than as a mental illness.
⋅ I also agree with the other comments saying that your paragraph on the dynamic system model of depression is too technical to be understood by most people. (I didn't fully understand it despite having read & understood your article explaining the idea several months ago.) The point it makes is important, but I think it would be better to explain it in a less technical way.
⋅ Regarding style: Your article is occasionally less formal than I would expect of this sort of article (e.g. "wearing rose-colored glasses and being a moron", "because the researchers were cowards"), but I'm not sure that's a bad thing: probably it makes the article more engaging to readers. Your clearly disclaimed descriptions of your personal expectations ("Secretly I suspect Zembrin probably works better than 5-HTP or St. John’s Wort, but there’s not enough evidence for me to recommend it", "I am positively predisposed to this substance because my girlfriend has used it successfully") may or may not be appropriate depending on how you intend to use this article: if it is meant primarily for your patients or prospective patients, these things are probably helpful in indicating your opinions/preferences to them, but if it's meant primarily for people looking for information on the internet, I'm not sure that they add much.
A big part of many therapeutic treatments is figuring out which beliefs you have that are helping you lead a constructive, happy life vs. which ones are just digging you further into your own unhappiness. I'm no shrink, but I definitely know people who think this planet is a miserable crapsack, but they're not unhappy because the most important thing in their life is the work they try and do to improve it.
That said, if you want to be happier without changing anything about yourself or your beliefs, I hear nihilism and hedonism both pair pretty well with this particular outlook.
Oh this is a much better reply than the one I was trying to come up with. In general it seems to me having unshakeable beliefs is a recipe for suffering because one is likely to seek out evidence to confirm that bias.
Random hot take, regard with caution: My belief is that this only makes you feel bad because you cling to hope that you're wrong.
By letting losses be losses you regain the ability to be content. Terrible is always relative to the status quo, and clinging to a specific status quo won't help the world anyways.
Maybe it would have, back in the ancestral environment, when due to smaller tribe sizes your dissatisfaction would've been a much stronger driver of tribal policy.
Considering how much worse things were for your ancestors, perhaps it's still not so bad as to warrant long-term depression since they clearly managed. Glass half-full and all. Then again, maybe all of our ancestors were depressed too.
For stuff like fish oil and L-methylfolate, could a person just eat foods (like fish and leafy greens) instead of supplementing? Or would you not get high enough levels of folic acid from eating a bunch of peanuts and spinach?
This is undoubtedly amongst the best and most useful things I’ve ever read. I’m just grateful that such an amazing and helpful write up even exists. I’ll be forwarding this to a lot of my friends.
Also n=1 evidence: the claim about the Mediterranean diet is probably true. I’ve increased my consumption of fruits and vegetables, and I think it has helped my mental health a lot.
I'm a guy in his late 20s, and many of my friends have some kind of diagnosed mental illness, and maybe this is just a factor of my artsy fartsy social cohort, but they all went through a mid-20s period of That Time My Depression Collided With Financial Self-Sufficiency And Access To Self-Regulated Cannabis and/or Alcohol. And for some people this was easier, and for some it morphed into a serious dependency or a stint in rehab, and two people killed themselves over issues that the weed or booze probably exacerbated. So, maybe to include a small section on substance abuse - specifically the most garden variety options - is unnecessary, or assumes bad faith, but this has proven so common a battle among depressed/anxious people I know, that I figured I'd be remiss in not mentioning it.
I'm probably bipolar, but for a long time I thought it was depression, and the best description I ever heard of depression was: You have a machine inside your brain that ascribes meaning to things - it renders jokes funny and sunsets beautiful and experiences good or bad - and that meaning machine is broken. The important thing is that your brain starts to miss when certain things meant "hope" or "pleasure," and to have all of those experiences that mean nothing of course becomes exhausting, but that's separate from the "lots of sadness" description I frequently see. Thanks for writing this - I think it'll help people.
I second the comments elsethread saying that 1. this is fantastic...for Codex readers, but 2. some of the nerdier bits are likely to switch off the general public. Dumbing things down does suck, though, so...I don't know. Presumably maintaining separate pages for nerds and not-nerds is out of the question.
> Many psychiatrists refuse to prescribe this medication because they are cowards, and I don’t have a good solution to this.
I chuckled at this, but it did make me think of a (seemingly?) parallel line from the amphetamines post:
> If none of these work, a braver person than I am might try Desoxyn.
Of course, you didn't exclude yourself, so no foul.
Hrm. Actually, having browsed around the Lorien site for the first time, I think I've changed my mind about this. The other articles are written at a similar level, so it won't be out of place. They're a breath of fresh air, actually; it's like all the most useful bits of the "more than you wanted to know" posts in one place. It's hard to find articles on these subjects that are written to convey meaning, without dumbing-down or obstructive ass-covering.
I don't understand how anhedonia differs from loss of interest in activities. I know that's not a list you made up, but perhaps your summary could be revised to make the distinction clearer.
Beyond that, I've always been interested in ECT as a one-stop solution, but I understood it was seldom practiced. Is it more common than I thought? Does insurance usually cover it? How expensive can I expect it to be?
Anhedonia - you do things you used to like, but you don't enjoy any of it.
Loss of interest - you don't want to do things, so you don't.
If you don't enjoy one thing you used to like, there might be a good reason for it.
If you don't enjoy anything at all, that's almost certainly some psychological problem.
Losing interest in some activities also sound normal if you find a replacement, but if you don't want to do anything at all, that's certainly a problem.
The former can lead to the latter, but not necessarily so.
By analogy (but also by things I had while depressed),
anhedonia is when food stops having flavor, ie your favorite food tastes like chalk,
and loss of interest is when you either don't have an appetite OR you're hungry but not hungry enough to go to the bother of having to choose a food and prepare it and chew and swallow it (which feels exhausting and overwhelming)
I've spent a fair bit of my early life managing and trying to dissect the cause of my MDD/GAD, so I hope this might be useful to others. Apologies in advance if this is a bit haphazard, I've accumulated various niknaks of knowledge from my own experience and others, and don't think it could all fit in a comment.
(Quick fyi: I think your page is already very comprehensive as it is)
I'll first start with things that I think might be worth adding to your page, and then discuss what has personally benefited me the most:
- There appears to be a fairly robust link between depression and inflammation, which I'm sure you're aware of but you may want to mention. A lot of the therapeutic or preventative treatments have an anti-inflammatory effect, including SSRIs (and fish oil, and exercise).
+ There's a compelling narrative that one can draw around evolutionarily advantageous genes related to infection protection and those that are implicated in depression. (This is the most comprehensive discussion I've seen on this line of research and would recommend watching it if you haven't: https://www.youtube.com/watch?v=6DtJGJWjDys).
+ Dr Raison discusses sauna as a promising method with an anti-depressant effect, and various studies which show therapeutic effect.
+ Exercise induces an acute inflammatory response, which is then followed by an even more potent anti-inflammatory response, just from felt experience I think this is a likely mechanism.
- Studies on psilocybin have been overwhelmingly positive but primarily focussed on terminally ill patients until recently. Cathart-Harris et al's recent RCT of pscilocybin vs escitalopram on people with ordinary (I believe unipolar) depression have been very encouraging, and in particular on their secondary outcomes. I would check that out if you haven't already.
+ I also think there is a very compelling narrative that can be drawn around how this fits with predictive processing and the self. (I speculate about this here: https://umais.me/writing/the-anatomy-of-wellbeing/, also links to Cathart-Harris's REBUS paper on the differential effects of psychedelics on different layers in the heirarchy)
Now, for my own personal anecdotal experience:
- Anecdotally, (mindfulness) meditation can worsen neuroticism, or self-referential thinking if you're already in the midst of a depressive episode. I recall Jon-Kabatt Zin (founder of mindfulness based CBT) mention something similar in his book Full Catastrophe Living. (there are some reasons why I think this is the case).
+ However, not all meditation is the same in my experience. Metta (loving-kindness/compassion) is a type of meditation that I believe _can_ be hugely beneficial in the midst of an episode or during anhedonia. Neurotic and self-referential thinking is a major driver for most depression, and by explicitly focussing on the happiness of others you relax this tendency. I really can not recommend it enough.
- Historically whenever I've tried using fish oil during an episode it has worsened my mood. I've tried this a couple times and was always a little confused given that I expected a placebo effect at the very least. I've read some stuff that suggests it could be oxidation of the fish oil but I was never too convinced. The Raison interview elucidates a possible mechanism that could be the reason why, at one point he mentions the apparent contradictory effect of an anti-inflammatory given _after_ inducing a depressive episode vs as a preventative before. With the former reducing cognitive symptoms but not the latter. Perhaps fish oil works as a preventative treatment, but worsens mood when experiencing the inflammation of an acute depressive episode?
There's a lot more I want to say on the topic, but it's 2am here and in the interest of sleep I'll end by just listing interventions along with my own totally arbitrary effect sizes ratings out of 10:
Great recommendation for the methylfolate. I’ve heard really good things about Jarrow. If you are on a lower budget there is a Winco brand and lots of others. But the effectiveness at the dose varies directly with price (at least for my kid.) To get the same effect at half the price it was about twice the dose. So we would roll along at an affordable “okay.” As he grew he needed more to get the same effect. When he was finishing a jar every three days we tried a degreed psychiatrist, but there were weird side effects for some things including the SSRI so we stopped. Then in desperation I located some T3 thyroid and it did help. Now I just buy the bovine thyroid supplements which taste awful but help.
I used 5-HTP for a few months and it helped some although I now see I was not taking enough.
Just want to put out a strong plug for Emsam: a patch version of an MAOI. It packs a bit less punch than the pills but still has quite good effects in a number of people, and crucially doesn't have significant amounts of the side effects that pill-based MAOIs have: there are effectively no documents cases of actual serious reactions from cheese/soy sauce/etc.
In section 2.6, regimen 3a and 3b, you recommend reading "feeling great" and doing all of its exercises, but in section 2.2.2 you recommended "feeling good" and noted that you weren't familiar with the contents of "feeling great". Probably you mean to recommend the same text both times?
Separate comment on the lorienpsych site rather than the post: Your category pages (e.g. https://lorienpsych.com/category/conditions/) have a *lot* of wasted vertical space, so much so that it's not immediately obvious I'm looking at a list; on load I can only see a single item. Some of the culprits I found in CSS: a fixed height:500px assigned to .blog-card-inner; excessive fixed margin/padding on multiple items under .blog-card-group; absolute positioning on .blog-card-inner-inner (indirect issue, breaks when the height is corrected).
The general design of the category pages suggest they were built from a template intended for an image-centric blog frontpage, not a page index. It is probably better to fix that by using a more appropriate template than by hand-hacking the CSS.
(On the other hand, +9001 points for putting your nav bar on the side when the view is wide enough, and for *not* making the narrow-view top-bar obnoxiously sticky. It's nice to know that some web designer somewhere declines to commit that particular atrocity.)
Thanks for this! I enjoyed reading it, and as a family doctor will consider suggesting this read to (at least the more intellectually inclined of) my patients going through depression. Just a couple of suggestions - I haven't read all the comments so others might have mentioned already:
1. At least where I am in Canada, psychiatry access is sub-optimal and the number of patients who would probably benefit from seeing a psychiatrist is smaller than the number who can see a psychiatrist. We do a lot of primary care mental health. When I read, "If you’re not sure if you’re bipolar, talk to a psychiatrist about it before trying anything on this page," I thought, wait a second... as a family doctor I think I am generally fairly capable of screening for mania/hypomania, and if a patient who I am convinced does not have bipolar believes that they do (this is a non-negligible number of patients) and insists on talking to a psychiatrist before starting anything I recommend... the delay could extend their illness significantly. Maybe this is context dependent, but I would consider changing this to "discuss this with your doctor before trying anything on this page."
2. Is there a reason you don't go into specific light therapy recommendations for SAD? Obviously there's lots you could cover and don't need to, but I think the minutes/lux etc might be useful enough for people to know, to justify including.
3. It might be worth at least mentioning as a side comment that there are some potential downsides to psilocybin? Here they sound totally uncomplicatedly good aside from being illegal.
4. Just a thought in response to the comments about education level - I think it's fair and helpful for you to target a higher education/reading level than the average person, because there is already a reasonable amount of (admittedly, less comprehensive) reading material about depression available at a lower level to the average person. I personally find the part about attractor states to have the lowest helpfulness-to-complexity ratio so if you were going to get rid of one complex idea, I would vote for this one.
My understanding is that light therapy is quite helpful, for many people, for almost any form of depression, not just SAD. Even bipolar depression - although then the person has to do the light therapy at lunch time instead of in the morning, to reduce the likelihood of triggering a manic/hypomanic episode.
I push this one bigtime, as it's quite easy to do and the lights have gotten really cheap.
So I'm not entirely sure what you're going for or who your patients are, but as a person who has been depressed in the past: I would not get through this. I would judge I am not currently depressed at the moment and I still gave up in the nutrition area.
For me when I am depressed, this would be both (a) way too much info, and (b) way too much hedging/inconclusive statements. Also, I don't know how educated your patients tend to be, but I would also judge this as written too highly for many--it assumes a lot of base info that I don't think is common knowledge.
I find concentration very, very difficult to maintain when depressed. While it may be useful/worthwhile to have the more in-depth info somewhere, it can't be the main page. Tell me what you want me to try. That's really all the info I can process. The links are good. I would prioritize having clear, precise, easy-to-follow directions for each point.
In more general terms: I have always found "additive" solutions more useful than "subtractive" solutions. Don't underestimate the positive emotional effects of "junk" food or other vices. Changing your entire diet might work, but I'm not going to do it and neither is anyone else I've ever known with depression (unless someone volunteers to be our cook). Start small: just add some carrots or something to the dinner you were already going to have. Don't join a gym, just watch some youtube aerobics videos, or take a walk around the block. The larger the ask (and remember, to a depressed person, things like "take a shower" can be monumentally massive asks) the less likely a depressed person is going to actually complete it.
My depression was mostly eliminated when I was diagnosed and treated for (actually rather severe) allergies that had an abnormal presentation and so were never noticed.
You've reminded me of a time when I was depressed (couldn't sleep, was crying a lot) and it went away when I cleaned black mold out of a plumbing access.
A nurse got confused about my chart--she was reading it at the start of my appointment for a sinus infection, and said "you were just in for this yesterday!". Except the date of my previous appointment had been for a year and a day ago, and that led us to realizing that I was getting sinus infections like clockwork every year in mid-April. So allergy testing was recommended.
I had no typical symptoms of runny nose, cough, sneezing, itchy eyes, or whatever. My only symptoms were recurrent sinus infections, migraines, and depression. When I did the skin test at the allergist, I reacted to everything so severely that all the welts ran together and made a big red rash on my arm--but, because my body is just determined to be weird apparently, it didn't itch at all, to the allergist's amazement.
I am allergic to mold and have had similar experiences. I *hated* one of my jobs, to the point where I could barely make myself go to work. About a year into it, a whole team of construction crews tore the facade off the building, because water had been getting between the brick facade and the walls and there was mold growing everywhere. My feelings improved after that. And I had a serious relapse when I moved into my current house--about a year after we moved in, we discovered that there had been a slow leak in the pipes in the master bath and that there was a massive mold infestation in the walls and floors. Again things improved after that was remedied.
This is excellent. This is the most informative post on a medical subject I have ever read.
A question on your suggested regimens: The only cases in which you recommend the L-methylfolate is when the person is also taking escitalopram. You recommend 5-HTP as a stand alone supplement, or L-methylfolate plus escitalopram, but you never recommend L-methylfolate as a stand alone supplement, or ever recommend taking both L-methylfolate and 5-HTP together. Is there a reason for avoiding taking both L-methylfolate and 5-HTP? Is there a reason to not take L-methylfolate as a stand alone if you can’t get escitalopram?
In the comments, a lot of people panned the ‘depression is an attractor state’ paragraph. FWIW, I found it extremely helpful— it really clarified the entire discussion for me.
A few minor suggestions
— typo ‘Less-well-studed’ should be ‘Less-well-studied’
— I’d suggest capitalizing the ‘L’ in ‘l-methylfolate’, to reduce confusion. People who have already heard of it no doubt pattern match the ‘l’ in ‘l-methylfolate’ to the letter ‘L’, but first I thought it was the number ‘one’, and then I thought it was the letter ‘I’.
—another useful item would be a list of foods high in L-methylfolate. You say it is ‘common in various vegetables’, but it would be helpful to know how much of what I would have to eat everyday to get the equivalent of the 15 mg supplement.
— word order ‘I still cannot recommend it enough’ should be ‘still, I cannot recommend it enough’
—I would highly recommend moving the link to the page on light therapy up to the first or second time you mention it, rather than all the way down in section 2.5.
> “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.”
For content like that, consider using sidebars that more technical readers can peruse but ordinary readers can skip over without affecting flow or comprehension.
These are mostly typos, and I'm not bothering to dedupe with other people, sorry.
The "attractor state in a dynamical system" paragraph could use a context/definition link. I know what you're talking about, but only from having read SSC/ACX.
"In a study in India" link spans too much text, and there is an extra comma at the beginning of the currently-linked text.
Add a period after "algae-derived version".
"Again, the most important answer" at the beginning of the exercise section doesn't seem quite parallel enough with the diet section to merit "again".
"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": "enough" is duplicated, and "medication give" doesn't agree.
I was hoping you'd say something about modafinil? There were a few interesting papers some years ago about them as therapies (particularly for atypical depression IIRC). My understanding from someone who tried to use it was that all normie psychiatrists laughed him out of the room asking for a script though. Do you have a strong opinion on it?
Consider adding untreated Celiac Disease as one of the diseases that can cause depression. I had no idea I had Celiac until I did a bunch of blood work trying to figure out why I might be depressed earlier this year. Turns out a gluten-free diet was basically all I needed!
I'm a mathematician, but I don't know what "attractor state in a dynamical system" means. I second others here: just scrap the "dynamical system" explanation, or rewrite it in layman terms.
This may be an edge case outside the scope of this article, or it may be helpful. I'm not sure, so I'm sharing.
I'm autistic (diagnosed with Asperger's back when it was still in the DSM), and have at various points also been diagnosed with MDD and GAD. If 1 out of ~50-80 people are autistic (estimates vary), and a substantial percentage of autistic people also experience depression (estimates of percentages vary), and something like 80% of autistic people don't have full time employment (which in the US is a prerequisite for most health insurance that isn't terrible)... I think we're a demographic worth considering, especially because a lot of the lifestyle-type changes don't work for us and we are more likely to have unusual side effects from medications (probably because of our neurological differences from allistic people).
For example, it's common advice (which you rightfully repeat) for depressed people to continue seeing friends, doing enjoyable activities, getting sunlight, etc. But for autistic people (or people with other disorders of sensory processing), these things can be overstimulating and make low mood (and its close friends, autistic meltdowns and shutdowns) worse.
Similarly, it can be helpful to take medications but (anecdotally) we seem to be more likely than allistic folks to get weird side effects to psychoactive substances. Do we just... Give up sooner on meds? Try more meds and suffer through the weird side effects until we find something that works well enough (which is what I did)? I genuinely am not sure.
Maybe the obvious advice is just "don't do things that make you feel worse." But it took me a long time to realize that forcing myself to do those supposedly-helpful things wasn't helping, and that it wasn't helping because I'm autistic. And I kept trying to do those things for a long time, because I take directions too literally sometimes, because I am autistic.
Unfortunately I'm not aware of research to back up these observations; most of it comes from interacting with the autistic community and reading a boatload of essay anthologies and memoirs of autistic people.
Certain gendered language could also be rephrased to be more inclusive. E.g. "people who get heavy menstrual periods" instead of "women who get heavy periods."
Thanx for this remark. Before I knew I was on the autistic spectrum things were much harder for me, too. Depression is such a universal reaction that dealing with it needs a lot of investigation. Most of the work one has to do alone. This is where things may get spiritual. "You have to walk that lonesome valley..."
I agree, even just a note saying 'if you might be on the Autism spectrum, or might have ADD/ADHD, etc, there are other considerations that need to be taken into account; these general suggestions may not apply as well.
And a mention of chronic pain? Apparently about 70% of people w/on-going pain are depressed :-( and treatment has to take that into account and be done differently.
First several grammatical things, like in this paragraph:
“On the neurological level, one line of research suggests depression involves neurons forming fewer synapses, especially in the hippocampus region of the brain. *Remember*, neurons are the type of brain cells which carry thoughts and information;”
I don’t think ‘Remember’ is necessary, you introduce neurons in the previous sentence after all. Broadly it might make sense to move most of this section to a special technical area, and just leave more vague gestures towards the neurologic, biochemical and so on. I like it but worry it might be intimidating. For formatting I like the way some sites will have embedded footnotes w/in the text but don’t know if you want to get into that.
“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 is difficult to visualize, I would add the 3D graph of local minima you’ve used before, maybe with an arrow to the negative point and a label “YOU ARE HERE”
“ (ie develop a negative prior on baseball skill).” Should be ‘i.e., develop a negative etc’
“ But another part of it is that knowing things isn’t enough. I know that if *I lifted weights* every day I could become very strong, I even know some more complicated body-building advice, but the advice itself is nothing” This sounds weird, suggest ‘if I were to lift weights’ or just ‘if I lift weights’.
“Either one when used for too long increases your risk of metabolic problems (eg diabetes) and various terrible movement disorders (eg you can’t stop smacking your lips, and this problem never goes away).” Twice in this one sentence it should be ‘e.g.,’ which means you overlooked four dots and two commas, that’s a lot of missing punctuation sir.
“ For one thing, you’re unconscious and don’t feel it. For another, you’re on what’s called a “neuromuscular blocking agent” which means you’re not really going to convulse (ie won’t flail your arms and legs around).” Here’s another should be ‘i.e.,’
“If your depression returns quickly again in a way that seems correlated with stopping the medication, stay on the medication indefinitely or until something important changes (eg you quit a terrible job that was making you depressed).” Probably should just find / replace the eg to e.g., at this point but I’m committed now.
Overall I think this is a really good and important article and I’m glad I read it and can hopefully make it slightly better. One other suggestion for an option if ECT hasn’t worked: neurosurgically implanted deep brain stimulators, if you’re not a coward that is. https://www.sciencedirect.com/science/article/pii/S089662730500156X
I think "If I lift weights" and "If I lifted weights" are both good English, with slightly different meanings. "If I lift weights" suggests more intention to me than "If I lifted weights".
"If I lifted weights" is grammatically counterfactual, like "If I had more time" or "If I were President". Using "If I lift weights" to express this counterfactual meaning would be incorrect and sound non-native.
You're right, there is a slightly different meaning where "If I lift weights" would be correct; like "I might, in future, lift weights, or I might not. If I do..."
But I think the "...I could become very strong" fits better with the counterfactual meaning.
I think you are being a coward for putting ketamine so low, and it is not difficult to get. 63 year old psychiatrist here, longtime private practice. I am a very skeptical, rational empiricist kind of guy, but I must say I think the word "miraculous" applies to many of my depressed patients responses to ketamine. Initially I was sending them for expensive IV infusions or IM injections, but I have been using nasal spray racemic ketamine made at compounding pharmacies for about a year now-- it's inexpensive, and dosed properly has minimal side-effects, principally dizziness or imbalance for a brief period after a dose, which diminishes over time. At 100 mg/ml, and with each spray .1 ml, most of my patients end up somewhere in the one-spray-each-nostril, one to three times a day range. I've had some non-responders of course, but lots of patients say no previous med has worked as well.
What makes it hard to find, I think, is psychiatrists who are not comfortable using/prescribing it. This is a barrier to a LOT of 'newer' treatments, especially those that go against previous medical wisdom, like naltrexone for alcohol abuse and low-dose naltrexone for chronic pain.
The discussion of treatments generally includes evidence from trials, but the section on ECT has only anecdotal evidence. An article on Aeon by John Read, a professor of clinical psychology, claims that trials of ECT show very limited evidence of benefits and that there can be serious and permanent side-effects.: https://aeon.co/essays/why-is-electroshock-therapy-still-a-mainstay-of-psychiatry
Is he right, or is there evidence of clear benefits from trials of ECT?
I was writing the following post then came across your comment. Given their similarity I thought I would post it here, in the hope SA responds to the points raised in the AEON article.
Perhaps the most relevant claim in the article is 'the ECT research literature as a whole has, from the outset, been of remarkably poor quality'. Is the commentary in the article accurate?
There's some research that shows that people who feel low often actually feel better when they listen to the sad music; validation and not feeling alone! But perhaps there's a time and place for that, not always the sad stuff.
Recognize the fear of ECT for what it is; recognition of a 'rather nasty but effective' treatment (much like chemotherapy for cancer), but also a component of out-of-proportion anxiety based in the popular image. The skepticism is interesting; do you actually not believe when people tell you there have been changes to how ECT is administered?
And when need be, we can do things we are afraid of.
"Doctor, my friend is depressed. What do you recommend?"
Cliche aside, this is actually true. This article is patient is oriented at what a patient or treatment can do, not what to do if someone you care about may be depressed.
I am not depressed but people I care about are. Is there anything I can, or should or shouldn't do? For example I keep inviting a depressed friend to social gatherings with a friend group (while those were still a thing prior to covid). He very often cancels at the last moment, and I tell him it's not a problem. I'm pretty sure he does enjoy it a lot when he does make it. But he knows he's getting a reputation, and is always profusely apologizing afterwards. Is this a beneficial thing to do on my part? I've asked and he says he appreciates that I keep doing that, so I suppose in our case it's fine, but I don't really know any general recommendations.
So perhaps it's worth adding a paragraph titled "My friend is depressed".
I don't know if that should necessarily be a part of this article rather than separate, but I agree that it would be extremely helpful. Some parts of this translate obviously into advice for friends/family members but I'd be very interested into what Scott's take as a psychiatrist is on how much you should prompt people to do things, in what circumstances you should recommend they get medical attention and so on.
Maybe I'm just unaware of the level of acceptance predictive processing has, but to me, the part on priors, etc., seemed more speculative than a lot of the rest of the post. (I know you like this stuff, but is it really known?)
I'm interested in the answer to this: I don't have any psychology/psychiatry background, but from the stuff that comes into my radar I feel like there's SSC/ACX stuff where it's taken as established, true, and explanatorily powerful, and then everywhere else where it doesn't get a mention (at least in terms that I'd recognise). But I don't go out looking for this literature, so I have no idea how representative that impression is.
I know someone who thought he might have depression when his actual problem was an undiagnosed auto-immune disease, due to which he was in pain. (The doctor said: "We prescribe an anti-depressant. If it works, we say it's atypical depression.") As soon as the auto-immune disease was properly controlled, he no longer felt depressed.
Maybe it's worth mentioning that what some depressed people with non-psychiatric issues need is treatment for their non-psychiatric problem.
YES, I think there needs to be a big bold mention that potential physical health issues need to be WELL investigated first. I saw an amazing Grand Rounds presentation years ago by a very senior psychiatrist, top guy in his field, about a 62 year old male, depression plus some cognitive decline, possibly starting dementia etc etc. The psychiatrist treated him for almost 2 years for depression etc etc. Then finally got thyroid tested and guess what? Presenter went on about what an idiot he felt like, and then revealed HE was the patient!
I also started treating a guy for severe anxiety, classic CBT, and it was two months before I remembered to query caffeine use. Sigh. Once we figured that out, we planned a gradual reduction and I told him to come back and see me if the anxiety didn't get better, or if it turned out he was self-medicating for attention problems. Never heard from him again ...
Hi! I'm a 19-year-old college student, and a lot of your regular readers seem more eloquent than I usually am. So excuse me if these comments are all over the place.
As someone who’s already a fan of your work and writing style and has suffered from major depression in the past (with occasional short relapses every few years), I liked this a lot. I can think of a lot of nerdy friends of mine who might find this helpful as a calm, empowering “go-to” about depression. (Sorry if the whole “nerds will really like your writing” comment is getting old. I would recommend this as a comprehensive guide to anyone because I can’t think of much else like it, but it does seem *mildly* inaccessible to people who are looking for immediate things to do rather than general information backed by studies.) In particular a lot of the comments are asking you add more detailed potential treatments - they might work if it’s been shown to help a majority of people, but I think the “cliche” treatments (life circumstances, therapy, medication, hotlines, diet and exercise) are still the most effective places to start 99% of the time.
I also loved the mentions of comorbidity with physical diseases and with other potential disorders. I thought that was handled really well, particularly in terms of what to look for in treatment.
I like that many of the suggestions are relatively achievable by oneself and don’t necessarily require professional help (though come to think of it, it might actually be useful to state the benefits of professional psychotherapy and medication a bit more, because I know very few people who have managed to single-handedly dig their way out of depression without any outside assistance, except for those where it was mostly based on one terrible life circumstance or something.)
One thought I had is that this might be less useful for people looking to support loved ones with depression - I can easily imagine an overenthusiastic family member reading this and bursting in with a bunch of ideas for potential treatment, which might not be the best place to start. The FAQ seems like a good length and well thought-out in terms of structure already, so maybe there could be a separate document for "supporting people with depression"?
Shorter notes:
-You recommend supplements for everything but creatine - could you add a reasonable creatine supplement?
-Seconding the person who wants treatment plan 3a/3b to be labeled as time/energy and doctor/no doctor.
-I feel like calling yourself a coward over ketamine is… I appreciate the straightforwardness, but I’m not sure it strikes the right tone.
-Why did the light therapy come after magnetic and ECT? I feel like since you mentioned light boxes before… I get that it makes the tone a little calmer though.
-Talking about anxiety and depression as having huge overlap then “make sure your depression isn’t caused by anxiety” in 2.6 is somewhat confusing.
-The instances in which you suggest something might work better but can’t in good conscience recommend it because of lack of evidence might give off mixed messages - desperate people might interpret it as “he’s secretly recommending the one with less evidence but is trying to be sneaky about it.”
In part 1, I found the paragraph on the attractor state sticking out negatively. You explain most other difficult concepts in simple terms, but you expect your readers to know what you mean by an "attractor state in a dynamic system". Also, while I understand what you mean, I found this fourth description to be less helpful than the other three.
There are some abbreviation that you assume your readers to know. I guess they know OCD, but do they know PTSD and DSM? (Little confidence, non-native speaker here.)
"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."
I think the HAM-D is a rating done by a psychiatrist (after some clinical interview), it's not a test that one can self-administer. So maybe consider rephrasing "take the HAM-D".
And maybe remove the word "exactly" :-) Such tests generally have low reliability (0.75, say). Let's say a glazier uses an instrument with that precision: it's like you order a window that is 1m x 2m, and then the glazier brings one with, say 80 cm x 170 cm or so...
I mean, can you really recommend it in a good faith?
If all therapies have roughly the same effectiveness on average, but one requires way more sessions for the effect - does not it mean that this specfic therapy is the least preferable of all. And that appears to be the case with psychoanalysis - it's more expensive in every aspect really. Longer session, more often, for longer periods of time.
I can see one case for it - if you have tried everything else and nothing helped, and that's your last hope. But other than that, why would you want to recommend it?
I think it works for some people better than for others. The issue with pricing is troublesome indeed, but I think Freud argued that there was something symbolic about sessions being costly, something like paying a price and leaving a part of you in there. It's hard because it has to be hard. I think it depends on the kind of therapist you go to (Freudian, Adlerian, follower of Winnicott or else), but sessions need not be long or short. Sometimes it takes longer, sometimes it takes only 15 minutes (and the price may vary as well, though today I think therapists tend to stop doing that). There is also a whole process of sitting in the chair then lying on the couch and transference that makes sessions inhomogeneous.
I'd recommend it if you want to know *why* you came to dysfunction at that moment of your life. Sure, antidepressants are great, but they don't do that. They don't give meaning to the particular kind of hell you go through.
Psychoanalysis has been shown to be an effective treatment for depression, as has it's less-expensive-and-time-consuming cousin, psychodynamic psychotherapy. And for all sorts of other things, including Borderline Personality Disorder. (Just not for anxiety, PLEASE PLEASE PLEASE! If you want to know all the deep reasons for your anxiety, go to psychoanalysis AFTER you do the CBT that will actually help.)
Yes, time consuming and expensive. But the changes are DEEP and durable. And if you can afford the time and money, a super interesting and often fun (and often very painful) experience.
Really enjoyed this; two thoughts I don't believe I've seen others bring up:
- The mentions of light therapy seemed a little scattered across the piece; it was a little jarring coming straight after the ECT section, and its inclusion there seemed more about providing humorous relief (a la 'arson, murder, and jaywalking' https://tvtropes.org/pmwiki/pmwiki.php/Main/ArsonMurderAndJaywalking) rather than because it fit well in that section.
- As others have mentioned the 'mathematical attractor' analogy is perhaps offputtingly-technical; an alternative analogy that captures the same broad sense could be an analogy of a surface with differently-sized holes (this is a gravity well analogy without introducing physics terminology), where some people's neurology/psychology/whatever is set up so that certain circumstances put their ball (current mental health state) near the 'depression' hole, and then it gets pulled further in; depression is one stable position of many/several. Interventions aim to bounce the ball outwards in the hope that it can find a different stable position.
(1) Everything following comes from an Irish context, therefore not universally applicable.
(2) I don't know if I have depression. I feel depressed, but at my initial (and only) assessment appointment for counselling, the counsellor said, quote, "That sounds like mood swings not depression" so I have no Official Diagnosis (my GP wouldn't even give me anti-depressants, again, quote, "We don't do prescriptions anymore" so I got shunted off to the "but now we do counselling!" route).
(3) Is there a difference between counselling and therapy? I feel like there is, but I don't know enough to say. Anyway, it was only counselling and not therapy on offer, if that makes a difference.
(4) I HATE, HATE, HATE, that in order to get help, you have to stick to acting out a script. I was ignorant of this, answered questions honestly, and as a result ended up with nothing. My own fault, I should have researched before I went in. Plus, ironically, having worked on the 'other side of the desk', I absolutely understand the requirement that "you have to sign this contract stating that you will indeed turn up for all the ten sessions of counselling", otherwise you don't get anything. I have been that public/civil service minion. I know what such schemes entail and why they have such conditions attached.
As a potential - patient? client? what is the proper term? - it felt very odd that executive dysfunction, which is a known symptom of depression, wasn't taken into account. On the very bad days, I can't even commit to getting out of bed. I can't commit to cooking a meal, even when there is food in the house and I am hungry and it will take 15 minutes tops. And you want me to sign a contract saying "yes indeedy-doo, I will definitely turn up every week on the hour bright-eyed and bushy-tailed for our session!", well like a fool, I said "I can't commit to that", so no counselling. (And I *understand* why! But it's still making me grit my teeth and scowl when the well-intentioned ads come on the radio about "help is out there!")
Help is out there *if you know the script and stick to it*.
(a) You cannot know anything about the problem. No, not even if it's something you're long-term living with. Doctors do not like it when you use medical terms; they feel like you're telling them how to do their jobs and that you're a hypochondriac who just looked up vague symptoms on the Internet and now think you have cancer. Dumb yourself down, you have to be the humble supplicant who is "oh doctor please help me, you are so wise and competent".
(b) Agree with everything (to an extent). Again, like a fool, I said "no" when asked if I was self-harming or had attempted suicide. Apparently just *thinking* about killing yourself doesn't count; unless you're self-harming or have attempted suicide, you are Not Really Depressed (Enough).
The trick here is to agree *just* enough to fit with the script, but not enough to trigger "well, better sign you into the ward for involuntary commitment". This is where the 'cry for help' attempt works best (e.g. take an overdose of something that won't actually kill you, call the ambulance, go to hospital to have stomach pumped/be kept in overnight for observation; get to see psychiatrist. Profit!). Unfortunately that won't work for me, as if I do ever get the courage to try suicide, I am not going to fuck around with 'cry for help'. I have a method that I know will work.
Anyway, next step!
(3) Agree with everything, part two. As I said above, even if you can't commit to washing your face tomorrow much less turning up every week, don't say that. Nod and smile and sign on the dotted line. Next week is a whole week away and who knows, you might even be able to turn up to the appointment on time, miracles do happen.
(4) Don't be honest. Even if when the counsellor trots out the watered-down quickie version of CBT which boils down to "think happy thoughts!", don't say anything except something along the lines of 'oh wow, I never thought of trying that". If you're like me and naturally sarcastic, bite your tongue. Sure, "think happy thoughts" won't work if your situation really *is* objectively shit, but you're not going to get anything better. It is now Gospel that CBT cures all, and if it doesn't work for you, the problem is you: you are Not Doing It Right. This is as good as you're going to get, so take it. Maybe it will help a bit.
(5) The main thing is, this is the script you have to act out to show that you are a Good and Deserving and Compliant Patient/Client. Otherwise, you get nothing plus you are tagged as a Bad and Non-Compliant Troublemaker.
I wish I had known all this *before* I went and failed to get the help that I am constantly assured is on offer, but there you go. Learn by my mistakes.
Yeah, it's only "learning by experience" that teaches these things, unfortunately, which means that it's too late when you do find out that you should have played the "I know nothing, I am from Barcelona" script. https://www.youtube.com/watch?v=nX7CeTXoxyU
"With lifestyle changes, you could potentially treat them the same way as medication, but also, consider sticking to a healthy lifestyle permanently."
Okay, enough of the pointless whining and complaining, time to try and be helpful.
Lifestyle changes are *hard* when you're down. Like I said, I can't even make myself cook something to eat when I'm hungry, and now you want me to draw up and stick to a regime of exercise and healthy eating and uplifting activities and - look, can I not just go back to bed and sleep for fourteen hours straight?
The "fresh air and exercise will make you feel better" thing actually had the opposite effect on me; it was when I *was* taking healthy exercise in the fresh air and sunshine that I seriously started contemplating throwing myself off a nearby bridge, the only reason I didn't go through with it was that I couldn't be sure the bridge was high enough to kill me instead of leaving me alive but quadriplegic or similar.
Well-meaning advice is really annoying and unhelpful, but on the other hand, when you're bogged down in the Slough of Despond sometimes you really do need someone to keep nagging you to change and stick to it.
CBT is NOT 'think happy thoughts', and anybody who is presenting that way is a shit therapist. Or maybe a counsellor (usually means less training (ie cheaper for the system) and traditionally counsellors dealt with 'general life issues' and not actual mental illness).
I possibly am being a little unfair there. I think that CBT will work really well for some people, maybe even many people, but that there will be people that it won't work for.
As Scott says, much of the advice for treating depression sounds easy but is hard to do. And the assumptions behind CBT (which I may be mistaken in taking as assumptions) seem to be that "things are not as bad as you think" - Scott's example of the person with a good job, a nice house, a loving family, etc. who thinks they've done nothing with their life. So the technique of realising and cutting off negative thoughts and instead reminding yourself of the positive reality works there.
Where your objective reality is not positive, then it does sound like "think happy thoughts!".
For me, the most useful way of conceptualizing depression is to think of it as a self-sustaining cycle: depressive thoughts lead to negative emotionality, constantly feeling bad leads to bodily dysregulation, and bodily dysregulation and negative emotionality *produce* depressive thoughts.
When I was suicidally depressed, that last part was very hard to even imagine, because I used to feel like I "was" my thoughts. As in, whatever I considered to be my self, my consciousness, my will, whatever you want to call it - that it was entirely isolated and embodied in my inner voice. I was the one doing the thinking. Whenever a negative thought popped into my head, it had to have been "me" who thought it, and therefore "I" was now thinking about that depressing thing and ruminating on it and pursuing its every implication for hours and hours, over and over again in order to get to some kind of resolution, some lesson to be learned, some revelation that would improve things if I just thought about it hard enough.
I was those thoughts. It never felt like thoughts could be introduced into my consciousness against my own "will". I thought, therefore I was (depressed).
And when anti-depressants seemingly failed to do anything at all for me, I took that as further evidence that I wasn't really ill ; I had by then reasoned that my depression wasn't anything abnormal, but that it was a rational, reasonable reaction to both my own failures and the general state of *gestures vaguely at everything*. How could I not be depressed? It would have been abnormal *not* to be depressed. Not being depressed was suspect. If I were to stop being depressed, it had to be because my reasoning became faulty. I had to have somehow become a less rational person ; which is, of course, absolutely unacceptable. Therefore, my fate is to be depressed and miserable, for the entire rest of my life. And since this is also terrifying, I have no other option but to (rationally, reasonably) kill myself.
I suspect this is a trap that a lot of hyper-rationalizing introverts with a huge ego tend to fall into.
What ended up helping me in the end was not to find a better way to think about my problems, but to not entertain depressive thoughts at all. To stop trying to figure out a rational solution, and instead force myself to notice when I was thinking depressive things and then simply decide to think about something else. Doing that is, as it turns out, way harder than it sounds - things like mindfulness meditation do help you figure out which mental muscle you need to pull to make that happen - but for me, after years and years of following the same depressive thoughts to the same depressing conclusions over and over again, I had gotten so used to all of it that I barely even bothered thinking it through anymore. I just caught myself and went "yeah, I know how that goes" and simply gave up.
As it turns out, that's basically all it took. I had some fears that I was repressing my thoughts, whatever that means, and that it would somehow end up making everything ten times worse - but over the course of ~1-1.5 years, I spent less and less time thinking depressing things, and while nothing else changed in my life, I found myself physically less and less depressed, up to the point where I could just say "I'm happy" and "I want to live" out loud, and it didn't sound completely and utterly alien.
I still have leftovers from that broken mode of thinking - for example, my instinctive reading of 2.1, when you write "the most powerful treatment for depression is GETTING AWAY FROM THE DEPRESSIVE THING", is that it says I should kill myself (since I am the depressive thing, and there's nowhere for me to get away from myself). Even though I know of course that you never intended it to be read like that, I know past me would have read it like that and believed it.
It would have tremendously helped me back then if someone had suggested just trying to treat some of my thoughts as potentially adversarial and unwelcome - and given me the assurance that doing that wouldn't really turn me into a different person. I am still very much the same I was back then in many respects, my life situation isn't that different, and the world is still generally as disappointing and as exciting as it used to be. The difference is, I'm no longer depressed and no longer suicidal, I am much happier for it, and I could have been like that 8 years earlier if I had had those mental tools back then.
All that being said, it is only what worked for me. I have no idea how strongly it reflects the actual reality of depression for everyone else. I do think the model of the self-sustaining psychological/biological cycle is an extremely useful mental health tool, because once you see it that way, you can start tugging at multiple sides of the issue at once instead of treating them separately. It also goes a long way in explaining the wild differences in treatment effectiveness between individuals:
1) People who don't usually spend their time ruminating and rationalizing can still end up falling into the attractor state and be kept there from purely biochemical factors - but any effective antidepressant should also pull them right out ;
2) conversely, people who don't really have anything badly wrong with their neurochemistry outside of what's directly caused by the whole "ruminating depressive things 24/7" will probably find antidepressants ineffective, and CBT super effective.
3) In most cases, no matter which cause is predominant at the start, you still end up getting both the physical dysregulation and the negative thoughts. Once the cycle is started, either of them can and will keep fueling the depression engine - so this also accounts for why psychotherapy and medication work better together than alone.
"a trap that a lot of hyper-rationalizing introverts with a huge ego tend to fall into"
It me. Most of the elements that helped me to recover from my terrible depressive spells in my 20s were external factors - moving to a town I like, finding work that I like and which pays enough for me to live, meeting & marrying my wife. Talking therapy has also been very useful, if only to set aside an hour every two weeks to put aside everyday concerns and take stock. However, in terms of the stories I tell myself, one useful technique has been to try to unbundle the self, for lack of a better term, through meditation & art.
Reconceptualizing the self not as a single monolith but as a confederation of different voices seems more congruent with my experiences in meditation. That realization that there's different inner monologues which are always running, not subject to conscious control and which are best regarded with a spirit of curiosity and lack of judgment was important. Some of these voices are internal representations of people who have been important to me and who seemed to find me wanting. This shift in how I conceived of my self felt as if it made the space for me to change myself, to realize that it wasn't actually these people and their opinions of me which was doing something to me from the outside but that one part of me representing those people was keeping the other parts of the self pinned down.
One artistic representation which I encountered recently and found very moving and useful as a mental shorthand is the passage in Hesse's _Steppenwolf_ where Harry goes into the room in the Magic Theater marked "GUIDANCE IN THE BUILDING UP OF THE PERSONALITY. SUCCESS GUARANTEED." Hesse came along at a good time for me. In some ways, I wish I had read him before, say, the French existentialists, but then again I might not have been ready to hear what he was saying.
It's a basic tenet of CBT (and a bunch of other therapies) to learn to disinvest quite so much reality in one's thoughts. To practice seeing thoughts as thoughts, not as reality. It can be really hard to help a person start down that road because investing a lot of reality in their thoughts is a deep habit and defense for a lot of smart people.
In then in a not-so-dissimilar way, Buddhist psychology and all the mindfulness practices are also designed to insert a gap between "this thought I'm having" and "what reality is." Their teachings about not investing too much reality in the "self" and all its shenanigans is central to that.
Yup, and CBT's new cousin, ACT, has an even greater focus on recognizing, accepting, then moving away from the 'not useful' thoughts and feelings.
I've found 'not useful' to be easier for people to accept than 'not reality'. That covers the thoughts/feelings that are disproportional, the ones that are distorted, the ones that are correct but perhaps we don't need to spend ALL our time focussing on them, the ones that we've thought/felt plenty about already and now perhaps we can move on .....
"Not useful" is a nice formulation. Buddhists tend to say "unskillful" and that seems judge-y for people who aren't on that road. The next layer down is that those thoughts and feelings are useful to some part of the person and that's what makes them so sticky. But there's not always room to go there with someone.
And that's a lovely way to describe that there are lots of different categories of thoughts that don't serve us well, from the more distorted to simply the ones it may not help us to marinate a lot in.
1. You avoid mentioning the term "dysthymia" (low-grade chronic depression) at all. I feel this is a very different beast than, say, a six-month major depressive episode, and lumping both under the label "depression" may be confusing. Dysthymia is both more subtle and probably more difficult to treat (in many cases, at least).
2. You mention "trauma" only in passing. I'm very interested in various trauma-oriented types of therapy (esp. somatic - Peter Levine's Somatic Experiencing, Bessel van der Kolk etc.) and IMHO this topic warrants more attention and space. It may be even more important than discussing meds. I suspect that _most_ cases of depression, esp. chronic (see item 1 above) are in this way or another related to past trauma, especially early trauma. When you write: "f you suspect that your depression is related to stress over a trauma you’re having trouble processing, I would recommend worrying about the depression only long enough to make sure you’re stable, and otherwise putting your effort into pursuing therapy for trauma.", it sounds like you're treating these two conditions as somewhat separate and independent, which I strongly believe not to be the case in a lot of situations.
3. Related to item 2, I emphatically DO NOT share the general enthusiasm about CBT-based therapies. I don't want to discard the evidence of scores of people who where helped by it. But for a certain type of people (myself included), CBT is one of the worst types of therapy available and can even be harmful. How so? In many people, a defense reaction against trauma (again, strongly correlated with depression, see 2) is some kind of dissociation, and in intellectual minded people this dissociation often takes the form of "locking oneself inside the head" (i.e. cutting oneself off from bodily sensations, emotions etc.). Mental/cognitive interventions only reinforce this pattern and keep the patient locked in their mind, despite treating emotional depression-related content on the object level (but, crucially, not on the process level!).
Much, much more can be said here, but I'll just try to highlight main points around this:
* Depression is often a surface symptom of sth else (e.g. past trauma) that requires deep transformational work to heal.
* It's impossible to do deep transformational work purely by intellectual/mechanistic means.
* As a culture, we like intellectual/mechanistic methods because: a) they have the semblance of being "scientific", so "predictable"; b) they allow us to disregard the body experience as something secondary (this is a very strong and old streak in Western culture in general, starting perhaps from Plato)
Therefore, we like CBT and tend to treat "less scientific" modalities with skepticism ("How do I know this is not some New Age bullshit? How do I know this is not placebo or anecdotal evidence?"). I don't necessarily advise doing "spiritual enrgetic DNA healing" as an antidote, and definitely there is a Pandora box of therapies that range from "not proven, but probably make sense" to "totally bogus". But consider the possibility that the scientific understanding of the body-mind relationship lags severely behind the empirical knowledge of practicioners. So "what can be proved in RCTs as of AD 2021" might not be the best indicator of what actually works, and it will take maybe 30 more years for science to catch up.
What is your proposed mechanism for how trauma contributes to depression? IMO there are many different possible pathways. The main three I can think of:
Presumably, in each pathway there are ways to ameliorate the depression by addressing the intermediates, rather than the underlying trauma. This is attractive because identifying the trauma at play is non-trivially difficult, and reconsolidating can be a disruptive process. When I did EMDR for cPTSD, it cut my productivity on treatment days by at least 50% — between that and the fact that trauma treatment is not really something one should do with a book and therefore requires locating a therapist and getting the requisite time and funds in order — it's not something everyone can make happen immediately. Obviously people with trauma should address it *soon*, but there are presumably many situations where someone is not going to begin treatment for another month or so but needs relief from depressive symptoms *now*. For these people, I imagine something like CBT can be a good way to prevent them from slipping further into the attractor sink in the short run, even if it won't make a huge impact long term.
I also am not sure I understand how CBT would make a person with trauma more dissociated with their body. In my case, before therapy I was basically totally detached from my body — I'd constantly get really bad injuries while running competitively because I wouldn't feel them until they became debilitating. Imo, I'm not sure there's anything that could have made me much more "in my head," let alone something like CBT which is mostly about challenging arising thoughts rather than adding to them.
Also, a word in favor of CBT — despite having trauma with a pretty serious bodily impact and being naturally pessimist (basically the two biggest risk factors), I only ever had one brief depressive episode, and it came from literally sharing a living space with people of the gender associated with the trauma. I just did the exercise/diet thing and it went away in a month or so. My sense is that this is probably due to the fact that I lack an inner monologue, and so don't deal with the whole rumination thing. Apparently this is a common observation and those lacking an inner monologue really are insulated from depression/anxiety. I interpret this as evidence that internal monologue has a very strong contribution and something like CBT really could make a big difference. This (monologue contribution) may be related to why depression is a Western illness, but that's speculation.
If I had to guess, this is why meditation is effective. It seems like most meditators are just trying to achieve mental chatter with low emotional salience, if not complete extinction thereof. My worry with meditation is that it changes the brain (adds to pfc, adds to hippocampus, subtracts from amygdala) in a way that might be helpful for anxious types but not for depressives. Should we really be encouraging depressives to do something that is designed to help people eliminate desires? Hence my preference for CBT, which seems more harmless. Although ofc I can't speak from experience here — I'm not sure how CBT would even work for someone w/o internal monologue. If someone finds out, feel free to inform me though! Maybe something like doing free association writing and then writing out responses?
I'll try to find the link, but I saw an article a couple of years ago that showed that meditation and especially the exercise/meditation combo improves learning (in the broad sense as well as the specific). So I'm betting we're going to find that those synapses and new/more connections are involved.
If that's the case, it could be useful in depression too, as long as the other work on reducing those negative priors etc is also being done.
HOWEVER, I have yet to see research that shows meditation actually WORKS to improve depression, per se. I've actually seen some (a few years ago now, though, so there may have been updates) good evidence that it does NOT, at least in reducing recurrence/severity/length of depression in people for whom it tends to recur. But I'm not up to date on this stuff, must go do a search now .....
And there are definitely other ways to deal with rumination besides meditation.
Thanks for mentioning dysthymia, I didn't know the term and I think it's a way better way to describe what I'm living. Do you know if the treatment for it differs from what is recommended here? I feel like at least most advice about lifestyle change would apply, but I don't have any evidence for it other than """common sense""".
Anti-depressant medications can make a huge difference for some people with dysthymia. Of course, like everything depression-related, it doesn't help everyone, nothing does.
For patients with dysthymia, I've had good luck using behavioural activation. Have to start small and help the patient be fairly consistent. Logging activities and mood/energy is VERY helpful for that, as the changes are subtle but add up, and of course, the dysthymia itself leads the person to focus more on the 'not-working-ness'.
The behavioural changes that are most often helpful that I've seen have been; more frequent low-key social contacts, more frequent exercise, preferably with other people and/or outdoors, and making their living space more pleasant/serene. That last one often takes a big effort with assistance; getting family or friends or a cleaning company or community services involved to do a BIG clean-up, sort-and-discard and re-organize. After that our goal becomes the small tasks the person can do on their own that keep the space nicer. I include some self-care in that 'more pleasant livings spaces' such as regular haircuts and shaving, having something nice-looking to wear daily. Not talking fancy clothes and certainly not uncomfortable; in good repair, fit ok, clean, colours the person likes ... I tell them this is part of their living environment, as they have to see themselves all the time!
I encourage people with dysthymia to see these efforts as an experiment; if they do all this stuff and feel/live no differently, they can stop! We figure out a reasonable time-frame for the experiment, and use the logging to see whether the changes are sustainable and whether helpful.
And most importantly, I tell them 'most people can determine whether they want to do whatever it is (socialize, tidy up, go to the gym ...) and then decide whether to do it or not. You, however, cannot! You need to figure out what helps, then DO IT, whether you feel like it or not, whether you think (in the moment) it will help or not, and whether it is immediately helpful or not!' I often compare it to having diabetes or any other chronic health condition; you have to do more to end up 'the same as most people'. We even make a list of 'actual reasons NOT to do the things you've determined are helpful', so they don't default back to not doing things (basically; would your doctor recommend you not go out to game night at the pub or not go to the gym today?'. If it's not on the list, they know they should do it. Having some kind of buddy system also helps; knowing you're going to game night and XYZ person is expecting you/will come by to pick you up if it's hard to get going/will text you to encourage you to go is great.
The thyroid thing was key for me. Most of my adolescence and early adulthood I had periodic waves of anxiety and depression. I’ve had nothing like them since I started treating my thyroid. My advice on this would be to include that many common thyroid conditions are *cyclical*, so a single thyroid panel may not catch it. I had one high result on routine blood work, which is why my doctor suggested we keep an eye on it, but it took repeated tests over nearly two years to see a pattern for me.
I had no pronounced symptoms, nothing “bad enough” that I even considered seeing a doctor. So we caught it early. In retrospect things like my mild-to-moderate anxiety and depression, concentration issues and high cholesterol were probably connected to my thyroid problem, since all of those things basically disappeared once I started treating it. Not to mention that I hopefully avoided the further trashing of my endocrine system, the results of which can be damn depressing all on their own.
The medication I take has been around for decades and is very cheap- if some people can manage their depression by managing their thyroid, that’s a got to be one of the easiest and most affordable outcomes, so if more people got diagnosed early it would be a giant win. But you can’t rule it out after only one test!
I remember one of the first things my psychiatrist recommended when I was first diagnosed with a mood disorder was to check the thyroid levels (the next thing was having me go through a sleep study), unfortunately that wasn't the issue for me (I think I was checked multiple times on this although this was roughly two decades ago so my memories are fuzzy), but nice to see it was a competent instinct.
I am compelled to comment on the connection some appear to be making between "dysthymia" and thyroid. My day job is that of a PCP, and I think that 50% of what I address most days is mental health. The root word "dysthymia" comes from the Greek "thymus" which is a term that generally means vapor or spirit or mind or emotion. Greek medical terminology referred to the gland within the mediastinum (essentially the space/potential space between the heart and the sternum) as the thymus. This gland produces T-lymphotes until early adolescence and then completely involutes, so much so that it cannot be found any longer in most adults. It is then reasoned that the Greeks named this particular gland, thymus, because it becomes nothing but a vapor. While everyone struggling with mood disorders, and many other things, should have their thyroid function checked, "dysthymia" and thyroid are similar terms. Perhaps this is the answer to the question posed by MK above about not mentioning "dysthymia"... people easily confuse it as being a thyroid issue when it is not.
Re: 4.: My depression (or at least depression/anxiety-adjacent experience, having never been formally diagnosed) manifests itself as feeling bad -> procrastinating -> not honouring commitments and/or increasing stress due to approaching deadlines -> self loathing -> feeling bad -> … The single biggest thing that helped me was using Beeminder, which I am fairly certain I discovered as a result of your 2015 post about willpower.
It is far from a magic cure-all, but it was so instrumental in helping me finally end a self-destructive cycle of failure and shame (and thereby helped me be ready to see and seize other opportunities to improve my life) that I am not being hyperbolic when I say that I believe it saved my life.
My first two goals were to do one pomodoro a day of productive work, and to whittle down the size of my inbox by ten messages. I'm a little more ambitious now, obviously, but that was all it took to get started on turning my life around.
I would have loved a citation or a link at the "drilling a hole into rat skulls and injecting BDNF cures their depression" mention, as well as one for how antidepressants treat good-reason-depression as well as random.
The non-technical explanation for your second question is that the medication (when it works) gives people a bit more strength to deal with the good reasons for being depressed and to keep functioning while they have good reasons to be depressed. They won't work for long or be all that useful if the 'good reasons for being depressed' aren't also addressed or changed in some way, they're not 'happy pills' that work independently of real life circumstances.
The one thing I would try to mention very early on: "Different remedies work for different people. It's important not to give up because you tried one thing on this list and it didn't work. Any given intervention has a less than even chance of alleviating your depression, but your odds get very good if you try three or four different things."
Why aren't biohackers playing around with TMS devices? I assume the main bottleneck is cost. A quick search suggests a TMS machine is in the $50k-200k range. But why is this? They're "just" a bunch of coils, and they seem easy and safe to operate. My best guess is that the coils need to be tiny and oriented carefully to give good spatial accuracy and precision, but even then $100k sounds like a lot. I'm quite confused.
I've experienced depression once in my life, last year after lockdown+bad breakup. Treated with venlafaxine with no withdrawal symptom (but my doctor made me stop *very* slowly, over 3+ months). All your advice about exercise and getting out of the bad situation matches my experience. What I find incredibly helpful in your post, and would have loved to read back then, is the plurality of causes and the link with anxiety. I couldn't help asking myself: "am I just anxious and sad because of this break up? is that genuine depression? am I a fraud and just making this up to feel better about leaving my partner?" I have no clue whether the scientific part of the article is relevant, but I cannot stress enough how important are the parts removing guilt and second-guessing for the patient.
At one point you refer to ECT out of context. Many readers will not know/remember what you’re referring to from the acronym alone.
At another point you say people should not “try” drugs or therapy if they don’t think they’ll like it. It seems to me you should say they should not -continue- if they aren’t happy with it. (I have a relative who “doesn’t believe in” trying either one, with a predictable (lack of) results.)
I agree with other commenters that some parts are likely too technical or detailed. For instance, maybe the reader doesn’t benefit from knowing your ranked order for prescribing various drugs. As another example, the bit about attractor states doesn’t make sense without more context (context which I’ve read in your blog before), but I don’t think delving into attractor states is super helpful for the reader anyway.
The word “availabilities” is not one I’d ever use. Perhaps it’s common in your field but not in the world at large?
I found it odd that you said people might not want to do therapy because it’s boring or hard to get to...without mentioning perhaps the biggest issue, cost.
It would depend on the market you are going after. If you want to appeal to the median ACT reader then this may not be a problem. But I think for most of your potential clients this paragraph doesn't add much value. I'm more of a business/marketing person so that is the basis of my critique:
"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."
"Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out. "
I'm not sure about that. I think there might be some selection bias going on due to your being a psychiatrist. You only deal with people who are seeking treatment. It's very likely they know they are depressed. That's why they are meeting with you. It's the people who are depressed that you don't see that are going through life thinking how they feel is normal.
1. I'm not sure if it's exactly on point here, but I'd like to thank you for your article about Zembrin about a month ago.
I'd been feeling depressed, but not enough to go see a therapist. Having trouble sleeping, not feeling motivated. I'd been trying to find a new job and was not successful. I guess technically I was/am feeling depressed but figured, 'this is just life and it sucks sometimes, there's nothing special that warrants help.'
After reading your nootropics article on Zembrin, I thought I'd give it a shot. I've noticed I'm sleeping better, dwell less often on negative things, and feel more motivated at work.
Even some OCD-like things I would do have stopped. For example, I often have the feeling when I leave the house that I need to go back and check that I closed the windows or that I locked the door. I would walk all the way down the driveway, get in the car, and then have to go back in to check, even though I knew it was irrational. I still sometimes get the nagging feeling, but I don't feel the compulsion. I'm able to say to myself, 'I know everything is fine' and I leave.
2. I was very interested in and surprised by the parts of this article that talk about the impact of making major changes. I had read (pop-sci type stuff) that people basically have a kind of homeostasis of happiness. Good or bad events can happen, but people usually revert to their individual mean happiness.
This always seemed like an argument against making major changes. Why make a change if you'll still just feel the same afterwards about the new thing. I know a person who is always changing jobs. They start off liking it, discover all the annoying things about it, decide they hate it, leave and then go through that cycle again at the next place.
I wonder if there is a way to discern which people will be helped by major changes and which people have more intrinsic problems.
3. Anecdotally, I have noticed that people do not know what will make them happy and should take a more empirical approach to the subject. I wonder whether there is any scientific basis for this or if it would be helpful for depression. I have made some major life decisions that I was initially reluctant to do on the reasoning of "other people have done this thing and seem very happy with their decision, so I should ignore my reservations and do it".
On the Hamilton Depression Rating Scale, for the Hypochondriasis part of the assessment, they include in the scoring "Querulous attitude".
Ah, so *that's* where I'm going wrong! Thanks, this made me laugh 😀
Re: the bits about "ask your doctor for this medication" - this makes the American medical system sound very interesting to me. I tried asking a doctor (not my current GP) for a repeat prescription of anti-anxiety medication and got shot down with "no, it's habit-forming". The initial prescription had been for ten tablets to be taken as needed over a six-month period. After six months I had used all ten. No dice on any more because that means I'm an addict.
Do American doctors really go along with "of course, I'll write that up for you" if you go in and ask them for a particular medication at a particular strength? Is this because of your health insurance system, where the doctor is an employee (so to speak) and 'the customer is always right'?
There are some significant differences based on your earlier comment about trying to find a therapist and having to say specific things and commit to a specific timeline to see someone. That doesn't so much happen here. But if the anti-anxiety medication you're looking for here in the US is a benzodiazepine, then you're going to get the same response. Benzos, while extremely helpful for many people, have come to be seen like opioids in terms of the reluctance that doctors have in prescribing them. So when doctors talk about "medication to treat anxiety" these days, they often just means SSRIs.
I'm in Canada and here, too, docs REALLY don't like it when you ask for specific meds. I go about it in an indirect, very respectful-of-MD's-professional-knowledge kind of way. 'I've heard that XYZ can be helpful for this, but I don't know enough about it. What do you think?' or 'my friend is taking XYZ for this, but I don't know enough to know whether that might be useful for me, too. What do you think, doc?'.
I straight up just ended up bullying my current GP into giving me one specific medication, when I knew all the good reasons to use it and she didn't have any actual reasons I shouldn't. I looked her straight in the eye and said 'Is there a specific reason you won't prescribe this for me?'. But I know that a) took a lot of balls, which not everyone has or should have to have to get good care!, and b) damaged the professional relationship with my GP long-term, a very not good outcome.
Recently I'm getting SOOOOOO fed up with coaching my patients to ask their docs (GPs or psychiatrists) for naltrexone for alcohol abuse and low-dose naltrexone for chronic pain/fibromyalgia/IBS combos. It's not working! Why won't docs at least go look it up and discuss it intelligently in a next appointment?
I am an "American" doctor, work daily in primary care, and evaluate and treat an extensive wide variety of mood and other mental disorders. Maybe a perspective from the inside of the system might assist in clarifying something for you. Patients do sometimes ask me for specific medications or mention medications they have researched or heard about from family and/or friends, and this does not offend me. My decision to use or not use medication is based on multiple factors including diagnosis, severity, potential therapeutic benefit, medication interactions, potential for adverse effects, comorbidity (other and potentially unrelated conditions), age, pregnancy, lactation, abuse potential, etc. I use benzodiazepines when appropriate and when the therapeutic benefit is high. I also decide against using them. I regularly prescribe most of the medications mentioned in the piece by Scott, and I refer to psychiatrists when the complexity of a particular patient is beyond my level of expertise or level of comfort. My decision to use or not use a particular medication or therapy or make a referral is never based on my employment status. It is based on what in my opinion is best for that individual patient.
Thank you for the article, and thanks for mentioning that feedback about typos is welcome. I haven't found any but I'm never sure if I should mention them if I find any. I like that it's explicit here.
Responding to your #6: I want to offer some general writing advice that I think will make this more accessible to your target audience without sacrificing the great information you've included.
1. As much as possible, limit the amount of new vocabulary a person has to learn just to understand a section. I know the point is to help your reader learn about new concepts, and you mostly do this very well. But in some places you're likely to lose people in ways that are avoidable. The routine use of words like heuristic, global, cluster, cognitions, algorithm, unipolar, allele, eosinophilic, receptors, etc will bog a lot of readers down. Many of these terms can easily be omitted or replaced.
2. Be very careful how you communicate uncertainty. Your blog readers are used to reading "I am very non-confident..." But most people feel insecure when someone in a position of authority talks like that. Alternative phrases include: "It is still unclear why", "The specifics of this topic are still being studied...", "There is some evidence that...", "Research is ongoing", you get the idea.
3. Be very careful how you talk about depressed people. I see the clinician showing through with sentences like "Depressed people are worse at simple sensory processing tasks..." The self-loathers will loath themselves more when they read that. You can easily re-phrase things compassionately, e.g. "Depressed people find it hard to..."
4. Avoid all-caps writing. Lots of people will read it as unprofessional. I think italics would work just fine.
5. Be sure to define your acronyms, even common ones like PTSD and DSM. I'm often surprised by the number of people who know nothing about PTSD. Plenty have never heard of the DSM. Perhaps you could embed some kind of pop-up definition?
Specific advice:
The short version: Do you want this to read like an abstract? You might take a different approach here and, instead of trying to list the things you cover in more detail later, just offer a few key takeaways that you want everyone who reads this article to see. I don't think you should list any medications in this section.
Simplify the "What is Depression" section. People will go straight for this section and they won't be prepared for what you've written. I think you could move a lot of the technical information to a subsection titled something along the lines of "How doctors understand depression" or "The science behind depression".
2.1.2: "But if you want secret/fancy things, the best evidence is... here". I'd rewrite the rest of this paragraph in simpler terms, eliminating the use of effect size (why introduce a new concept if you're going to talk around it?) and the discussion of good vs. bad placebo-controlled diet experiments. These sentences will confuse and derail the average reader. For someone interested in this stuff, you could include it in a more technical article.
"We still don't know much about nutrition... the researchers didn't check" is written in a fashion that will induce anxiety in anyone who is uncomfortable with uncertainty. I'd try out some alternative phrasing like "Research in nutrition is ongoing and will likely turn up new things in the future"
That said, I'm ok with how you express uncertainty regarding exercise in 2.1.3, therapies in 2.2, and supplements in 2.4 because those instances help you make your point.
2.2.1 Please include a therapy option for low-income people and those without insurance here. I don't know what the alternatives are in your area, but in mine (Southern Oregon), the low-income clinic offers really cheap therapy sessions where you're counseled by a therapist-in-training, and I know people who have benefited just from that.
2.3 If you don't have much advice to give about psilocybin, you probably shouldn't mention it until you do. I know too many people whose psychosis started with the casual decision to take mushrooms on a daily basis.
By and large, I think you've don a lot to make this piece accessible to a lot of people. Some of the most accessible sections were located later in the article. I think you could work to simplify some of the writing in the earlier sections, the sections people will likely read first, so your readers don't get discouraged early on. In general, I enjoyed it and I thank you for putting it together.
PS- Please including something about postpartum depression when you're discussing what causes depression. It's a big deal for a lot of people. I also know women who experienced unexpected depression during the hormonal fallout of a lost or terminated pregnancy.
This is an important point, especially given that postpartum depression comes at a time when time & energy are likely at their highest premium at any point during adulthood. Caring for an infant is a strain even for couples who have a healthy relationship & strong social support, much less single parents or couples with problems.
> In a study in India, , 40% of vegetarian women vs. 7% of omnivorous women had moderate anemia, a common consequence of iron deficiency (anemia is much more common in women, but some men can get it too). Symptoms of anemia include looking pale, feeling easily exhausted, feeling an urge to eat weird things like ice or dirt, and – yes – depression.
Extra comma + 2nd sentence repeats what was already said.
> The most-studied and best-supported supplements for depression is l-methylfolate.
supplements -> supplement
Is seasonal affective disorder a subtype of depression, or more of its own thing? I suppose diet/exercise and most of therapy recommendations apply regardless, but what about medication? If you have clear and stable seasonal patterns in depression symptoms, does it make sense to try melatonine as a 1st tier (instead of or alongside prescription antidepressants/5-HTP)?
Also not directly related to this guide, but I'd like to ask a question about vortioxetine. I have a relative who uses it because she was told that it does not tend to cause cognitive problems, unlike the cheaper options (even though money is an issue for her). Do you have any information about it? I think I've found an estimate that ~20% of regular SSRI users experience cognitive problems as side effects, but - in your experience - how bad these problems tend to be, e.g. at the median level (supposedly ~10th percentile of overall users) and 5th percentile (supposedly ~1st percentile of overall users)?
Also, I think the diet section would benefit from a clarification regarding soda: is its sugar content the problem? Should diet Pepsi be considered mostly harmless, or mostly like non-diet one?
My anecdote is that zinc was life changing for me. I realized the only two times since puberty I wasn't suicidal were when taking zinc for my acne. Did some research, saw some links between zinc, estrogen, and depression. Ran an experiment. Never retested hormones because I didn't care why it worked just that it did. Most of the time I was taking 50mg/day, but I've tested and 25mg a day is the minimum for good effects in me.
August 8th 2016 (day I started taking zinc again)
Goldberg depression: 46 (representative of my life since 2004 or 5 or so)
Estridol: 37.8 pg/mL (Apparently a little high for a 22 y/o male)
Total testosterone: 624 ng/dL
Sept 27th 2016
Goldberg depression: 17
Feb 12th 2017
Goldberg depression: 13
I later found Prometheus claims I have a gene for poor zinc absorption. Also I've switched my opinion to my "true" diagnosis being cPTSD related to ways I was touched I didn't consent to. I still have some executive dysfunction issues I'm unsure what to do about and some anhedonia symptoms but I'm no longer an active suicide risk so that's neat
What I personally found missing in this otherwise quite extensive article is mentions of socializing. As a person with ~7 years of depression under the belt, one of the things that help a lot is making sure I don't stop meeting with people I like who like me. I think a (newly) depressed person might benefit of a lifestyle reminder that "if possible, keep socializing with people even if you feel tired, sad or useless, as long as people you're with don't make you feel worse". It definitely slipped under my radar at first
Typo: "if the medication give you" => gives you in 2.1
"ECT" near the end of 2.3 should be expanded to Electro Convulsive Therapy (or however it's generally typed) because it takes a second to recall what that means
Attractor state paragraph ("mathematical explanation") is probably incomprehensible for people who don't already know what you're talking about (I do, because I've read your stuff for a long time), and could use more links/expansion/a picture.
Could you annotate the article with references to primary (or other) sources wherever possible ? Maybe not at journal-publication level rigor, but perhaps at a Wikipedia level of detail.
1. Give examples of very low goals ("wash your face when you wake up") so that people will feel that it's ok to go that low. Also because very depressed people might have hard time thinking on goals.
2. Encourage people to undershoot in their definition of success. It seems that doing something very easy consistently is better than doing something bigger but only 80% of the time. I believe it is because: It gives you a sense of accomplishment, it build an habit (see "atomic habits"), and finishing your task with energy, it's still possible to do more if you feel like it.
(Disclaimer: I think this post is really good overall! Just offering what I think is worth considering re: changes.)
Maybe consider explicitly flagging the potential for bipolar 2 to be mistaken for depression? One of my main personal experiences with depression is watching a friend be treated for depression for several years, then find out she actually has bipolar 2, switch medication, and improve some (it's hard for me to say how much).
My vague impression is that the bipolar 2 / depression misdiagnosis happens a lot, especially to women; and that people generally don't know about bipolar 2, because it's not "classic bipolar". If it's not actually common, then it's probably not worth including.
Probably the place to edit is "If you’re not sure if you’re bipolar, talk to a psychiatrist about it before trying anything on this page."
Thank you for this helpful and (like all your work) compulsively readable overview. A note about tone: I like a lot of the informal style (e.g. “The procedure itself is surprisingly non-scary”), which comes across as friendly and accessible, but (like others in the comments) I think you should be more careful about the ways you express uncertainty (e.g. “Maybe this should be a second-line option and I’m being a coward by putting it so low down”). In particular I disliked asides about secrecy (“Secretly I suspect…” “if you want secret/fancy things...”). I understand the desire to be honest about how medical knowledge is incomplete and developing, but I think it’s also good to inspire or maintain some confidence in medicine. Even when the doctor is saying, “Medications that are very helpful for some people do nothing for others, so we may to have to try several different antidepressants before we find the right one for you,” you want him to say it in a tone of cheerful competence that implies he knows the process inside and out and has a reliable system. “I can’t overemphasize how much great work by brilliant scientists has gone into this question, nor how totally useless and conflicting all the results have been” strikes me as funny, knowledgeable, and frank about uncertainty, while “I have never been able to get my patients to a high enough dose to test this; they get too many side effects and give up” is rather worrying.
For me, the idea that no one really knows what works or why it works and we’re just throwing powerful chemicals at problems to see what sticks is a major argument against psychiatry; I would need either gentle, patient explanation or despair of any other solution to be persuaded to try psychiatric medication, and any flippancy about the degree of uncertainty involved would increase my hesitancy. Probably it really is a free-for-all where the treatment you get depends on the idiosyncratic preferences and pet theories of your psychiatrist and nobody should get involved without fair warning, but to overcome anxiety as an obstacle to treatment, it seems helpful to increase the salience of knowledge and expertise and decrease the salience of experimentation and trial and error, insofar as that is compatible with honesty about the facts.
I agree with all this. As a psychotherapist I see a lot of people who might benefit from medication at various points but are absolutely terrified to try them, not surprisingly especially the folks who have anxiety in addition to depression. So a certain amount of cheerful confidence about giving it a try seems worthwhile, as does refraining from too much ambiguity-raising. At the point that a doctor is prescribing a specific patient a specific medication, there's appropriate room there to provide solid informed consent, including some of the equivocations and ambiguities. This article doesn't seem to me to be that moment.
I also find it helpful to discuss their specific fears (usually 'it will make me a completely different person' or 'it will make me happy like a zombie despite these bad things happening in my life' or 'it will make me addicted and even though I won't like it I won't be able to stop' or 'I'll get EVERY ONE of those side effects everyone rants about on the subreddit and they'll never go away' or a combo thereof) and realistic expectations.
Then also to emphasize that EVERY thing we try, including meds, is a single n experiment. If it doesn't help after a reasonable amount of time/dosage adjustment or you just hate it, you stop!
There's also an underlying fear, too, that needs to be addressed; 'What if I try meds and even THAT doesn't work? Then I'm really really doomed. So I just won't try them, so I don't have to experience that fear.'
Just for an alternative viewpoint: when I seek help from medicine, I really dislike the cheery optimism point of view. I'd much rather have my expectations set appropriately, even if they should be very low, and I would actually be reassured by informal signs that the physician was being completely candid -- which a touch of smartassery and revelation of his own struggles with the field provides.
This is probably not a useful opinion, as I've never sought treatment for depression, but I thought it might be mildy interesting in an academic way to observe that not everyone wants his physician to make an effort to be cheerful and optimistic. I sure don't. If his first impression on seeing my scans is to exclaim "Jesus! You'll be dead in 6 weeks!" I'd actually rather my physician blurted that right out. It can only get better from there.
This is so true for so many people, Carl! The artificial optimism and positivity is SO hard for any reasonable person to handle, never mind a depressed one! It's very helpful to give people realistic expectations or what can/will help and how much and how likely. I find it especially helpful to mention something like; 'well, given your symptoms and preferences, we'll start with this, and if this doesn't work, we can try that or this other thing and there are more options after that'.
Healthy optimism says 'there is probably something I can do to influence what is occurring and bring some improvement', not 'everything is or will be great!'.
Weird thought: suppose we thought of depression as a weird form of prejudice or bigotry against yourself, in the manner of racism or sexism? Thats what the talk of global reduction of optimism and the need for raising your self esteem makes me think of. May not be a particularly useful perspective though.
I have experienced depression as anger held, and found that expressing anger healthily relieves my depression. And I note that anger is not mentioned here, which angers me slightly, so I am writing this comment.
This is a bit ambiguous: "Take 5-HTP 100 mg, increase after one week to 200 mg, increase after three weeks to 300 mg." Presumably means "increase three weeks after that to 300 mg".
I appreciate the importance you place on lifestyle change here. The resistance to it certainly is hard to overcome when underneath the weighted blanket of depression, but I can share a nugget of success:
I had severe treatment-resistant depression, more or less preventing me from holding down a job. We tried it all: CBT, escitalpram, buproprion, fluoxetine, sertraline, strapping magnets to my head, etc etc etc. The next step was ECT, and if that didn't work, the step after that might have been pretty dire.
So, I started volunteering at a local shelter, just one night a week. Very small ask of myself, and their sheer need for volunteers meant that there were no barriers to entry. It gave me a bit of accomplishment, a bit of self-respect, and some conversation ammunition other than 'I've been miserable in my apartment all week, thanks – how're you?'
They quickly noticed that I was invested in the work, and that I had time to spare, so I was promoted to lead volunteer, two nights a week. Slightly bigger ask of myself, somewhat more of a sense of accomplishment and self-respect. I started to build a bit of a community there, and weaned myself off my SSRI soon thereafter. It went well.
Bit by bit, I eventually clambered my way up to a management position, and have now been working there for three years. I have some bad days, but my depression is effectively over.
This plugs in well with your section on behavioral activation – the trick is making gradually bigger asks of yourself, which feeds your mental health enough to take the next, bigger step, until, whammo, you don't want to kill yourself even a little bit!
I found the stuff at the beginning about whether depression is just an emotion a bit misleading. In particular, it makes it sound like emotional states generally don't have real and profound physical and health effects. I mean, I ultimately think that the flaw is this idea that anything just in your head or your emotions isn't serious or doesn't require real treatment but wherever you identify the issue it seems mistaken to prop up the idea that emotions fall on one side of a clear divide and try and argue depression is on the other.
I don't know if I would change it since it makes sense to be more worried about people misinterpreting it in a way that is dismissive to depression but just my 2 cents.
> 2. Sleep problems (could be anything from having unusual trouble falling asleep, to waking up too early, to sleeping too long)
Isn't that a bit of a narrow window to squeeze through ? This sounds vaguely like getting anything other than 7.892 hours of sleep per night is an indicator of depression.
The way this gets described usually is recent changes in sleep or appetite. Eating or sleeping either more or less than is usual for you, the usual for you part being key.
As someone in a current depressive episode, I can only say that I found both the short and long descriptions exceedingly helpful for my current situation. Though my concentration is limited right now, I was able to follow the long description and skip to items that resonated with me in particular. I appreciated the amount of information; even though I have been grappling with chronic depressive episodes for years, my depressed brain sometimes convinces me that I'm not really depressed, so having the in-depth discussion of criteria and clear, precise ways to manage it were really enlightening, even to someone very familiar with the general information and treatments. I think what I appreciated and liked the most is that you very clearly articulated how hard some of the willpower-based treatments could be, but that even small steps are helpful. (Once I was too depressed to get out of bed, but I made myself clean the top of my nightstand. It helped. The next day I was able to do a little more. I use this method now when I feel too depressed to do much, and like you said, it makes me feel successful.) Personally, I've found DBT particularly helpful as a treatment, even though it was designed more for personality disorders than depression, but the skills are concrete and easy to remember, and I would enjoy seeing your take on it. All in all, I was grateful for the post and will be bookmarking for the future.
Also when you make claims like "On the cognitive level, depression is a global prior on negative stimuli." it sounds like you are defining the condition not offering an observation about what it involves. I mean I doubt that is part of the DSM 5 diagnostic criteria and it also has the potential downside of potentially confusing those of us who have been depressed but we're sufficiently aware of it to correct our best guesses about outcomes.
When my depression was pretty bad I could always tell my psych a reasonable probability distribution for what would happen if I took any action. It was just that the negative outcomes loomed larger and somehow were the emotionally salient aspect.
Also when you ask "1.1: Is depression caused by biochemistry or life events?" I know what you mean but it might help to make it more clear that you mean what is the factor that dictates who gets depressed .. I mean in a certain sense all mental events have biochemical causes but I'm probably just not picking now.
I only have things I wish you'd add, can't find any other fault.
Within your framework about depression as a neurological disorder with easy-to-notice mood effects, I was really hoping you'd spend a couple of lines on chronic migraines because I think there's a strong link there.
You make it sound like getting away from the depressing thing is only for people who have a clear sense what their depressing thing is. And while within depression it can be hard to identify, because everything feels depressing. But this is worth a dedicated investment of time and focus on. If you can't think while stuck in your room, go somewhere else to think about that. If you can think best while talking to people, talk to people or a therapist about it. If you can think best while writing, write it out.
The depressing thing can also be a lack of something, not something that is there. Lack of an important and worthwhile task, or lack of meaningful relationships, can be sufficient.
Pretty sure low testosterone can also cause depression, and is relatively easily fixed.
Not sure why you almost don't mention drug abuse. Maybe because you don't want to lie and say they never help, but saying anything else risks your license? Regardless, I think this is important. Most depressed people I know are abusing SOMETHING and depending on what it is that can change the situation a lot. Mood-altering drugs make the obvious mood-related components a lot less obvious, which makes depressive episodes easier to suffer through but also makes depressed people not seek real help. Illegal drugs make it MUCH harder to seek help.
Needs a section on pregnant and breastfeeding women, because their treatment options are different, they get depressed a lot and mothers are extra important.
Also re medication treatment I was very successfully treated by a psychiatrist (emminent addiction specialist actually) who ended up prescribing me Adderall and there are studies which back this up. I was eventually also semi-diagnosed with ADHD but even after 15 years or so the Adderall prescription for depression is still working great (tho no doubt getting older and married helped too). I don't know if you want to mention this since it obviously won't help patients to go be asking for it but it did work great for me.
I also appreciate how you remark about how ppl often give up but I think you might want to make a stronger statement on that. I know my tendency was just to take the meds the doctor gave me and not complain too much so even when Prozac was doing nothing for me I kinda just didn't want to cause a problem. I had a doc who pushed me on whether it was working and moved me on but that was a retired emminent psychiatrist and I know friends who just get lost bc they managed to get up the courage to tell a gp once get a Prozac script and then feel reluctant to complain. One of my friends even died thx to that kind of issue (semi-intentional opiate od...as in delibrate indifference and desire to die leading to risk taking).
I think that's something a number of depressed ppl struggle with (feeling like they are being a nuisance if they say still not better) so wouldn't hurt to mention.
Ohh sorry for comment spam but one other thought. It might help to give some sense of how much more helpful it is to also mention this to your doc than to just take supplements and tell yourself you are going to start execising.
I know that many ppl who are depressed are reluctant to tell a doc or ask for help (I was when I was horribly depressed and I let myself lapse into problematic opiate use rather than raise it with a medical professional until it all kinda fell apart) and I fear one common temptation will be to see all the diet stuff and use that as an excuse not to say anything to med pro.
That might be the right call for some ppl but I fear that the impression many readers will take away is: hey there is evidence for this diet and other crap and here is a psych spending just as much space on it on their website so it's probably fine just to do that and not tell my gp. I mean yes you say it's better if you have access but that's not until much later (many ppl won't read that far) and can easily be brushed off just as: well of course a doc prefers seeing a doc.
I'd include some stronger statement about the efficacy of treatment from a good psych over just trying to change your diet on your own. I know you probably won't be able to cite a research paper on that but nothing is wrong with just conveying your impression as a working mental health pro.
And more generally giving your personal sense of the relative usefulness of the various treatments would be very helpful.
In terms of mental health one of the best things I've gotten from your content was a layout of how you rated various treatments for anxiety in terms of strength/effectiveness (might be misremembering slightly). I mean those of us who can read sci papers but aren't docs easily end up with a bunch of papers saying X works or Y works but no real good idea (thx to high noise and different patient pops) what the relative effectiveness is. Ok so this diet helps some ppl but is that just as good as an ssri or just something that regularly helps a small fraction of ppl or a tiny bit but doesn't hold a candle to ssris.
Sorry one last thing. I'd love to see some remarks on anhedonic versus the other kind of depression. I don't know if this is the right page but I know that back in the day (15 years later might be different) when my doc talked to me about anhedonic depression versus other kinds I had trouble finding much useful online at my level which explained what that meant and how it impacted treatments etc.
If you are writing this to be read by possibly depressed and or anxious people... you might want to define stable (from the section about trauma in the 'do I have depression or something else')
"I would recommend worrying about the depression only long enough to make sure you’re stable, and otherwise putting your effort into pursuing therapy for trauma."
You know what you mean, but your reader may not. Part of the joy of your writing is it is clear, and often rises to making complex ambiguous things not ambiguous, like the adjacent 'look stop trying to decide if you are more depressed or anxious, just get you depression-anxiety treated; bit.
A depressed or anxious person (or somebody who knows one to the point they are reading your web page about depression) may be wondering, or may need to be wondering, if the depressed person is 'safe' - and if they are not, what to do. I recognize safe is hard and crisis is hard and you probably cannot write to that without clinical evaluation (and perhaps not even then easily) but when I read 'stable' it filled my head with questions.. do you mean not suicidal? Not bipolar or suffering from wildly changing levels of depression? Not... what? ... all of which is a close proxy for 'safe'.
When I was clinically (and situationally triggered) depressed/suicidal, I got real close to actual suicide before I and others around me recognized I was not only not stable I was not safe - something I should have recognized earlier (except I was, you know, depressed) and something those around me might have recognized earlier (except, of course, I had been depressed for a bit and therefore not acting normally / masking my depression / they were the trigger of my depression and were dealing with their own depression and issues / etc).
If you haven't experienced it before, you may not know when you have crossed the line between great, ok, sad, depressed, and DANGER! ACT NOW! - having been through that journey once, I feel like the odds I will recognize 'oh shit I am feeling/not feeling that way again; plus be willing to ask for help, even significant intrusive scary help like hospitals and leave from work and such, are much much greater. I worry how to communicate that effectively to other who haven't been there seen that before...
- My own experience for context: my mom died of cancer and some other bad/tough stuff happened to my family, and then we had a baby. For somewhere between several months and 1.5 years, I was irritable, unmotivated, not much enjoying things, sleeping too much, and drinking heavily most every night. My wife told me she didn't think I was okay and asked me to try therapy, and I was resistant for a long time. Now, due to some combination of time, lifestyle changes, and therapy, I'm doing rather a lot better. The points below are based on some of what I can see in hindsight were challenges.
- If you are some combination of analytical/knowledgeable about psychology/used to being self-reliant, you may have some resistance to a "diagnosis" of "depression" - if folks close to you think you need some help, consider the possibility that they are seeing something you don't and that getting some kind of help might make sense
- Also, note that the depression-related pessimism might strike here as well: you will be less likely to think that treatment will be helpful and more likely to think that it reflects badly on you or others will think less of you for seeking treatment.
- Especially for depression brought about by a life event (like grief over the death of a loved one), know that it might take some time and that intellectually "understanding" what has happened is not the same as working through the feelings and associated physiological changes caused by the event. This can be especially troublesome if paired with the resistance to help above: you are "fine" because you've "dealt with it" on an intellectual level, which makes you even more resistant to seek out help.
- Building further on "whatever lifestyle change you will actually do", consider lowering your standards of what "counts" radically, as low as you have to to get to something: for example, you might want to do some fancy combination of high-intensity cardio and weight lifting, but you're having trouble getting out of bed. Going for a nice, easy walk while you listen to some music or a podcast might be an easier sell. With diet, rather than going for a strict modified Mediterranean diet, maybe just make sure you eat some salad once a day. You can always ramp up later, and getting something you can do consistently is more useful than getting it perfect for a few days and then finding it too hard to stick with it. You make this advice clear in your specific regimens, but as a general rule for behavior change, I've found "make it so easy you can't not do it" to be really helpful, especially when feeling unmotivated/depressed.
- Anecdotally, I've had some good results from hot and cold exposure, though hot exposure (sauna, bath) seems better for relaxing when feeling anxious (unsurprisingly), and cold exposure seems better for dealing with lethargy/lack of motivation (again, unsurprising). I've heard that there might be some studies to support this, but no idea if they're any good or what they are. I also know ice baths were a treatment for depression back in Victorian times, which was not too long ago was seen as senseless barbarism, but now some folks are like "maybe they were on to something". Wim Hof has a good program for easing into cold exposure through incrementing up how much time per shower you spend with it cold: https://explore.wimhofmethod.com/coldshowerchallenge/ . These benefits might partly or wholly be of the "I did something intentional to help myself" variety you discuss
- Take note if you are "self-medicating" in some way: common forms include frequent and/or very high consumption of alcohol, pornography, or other things that reliably create short-term feelings of well-being. This can be very sneaky: you may just feel like you "like" the substance/activity. Again, if folks close to you are concerned about it, that's an indication that it might be more than just "liking" it.
+ I see you mention psilocybin, but very passingly, for obvious reasons. My own experience is that taking psychedelics a few times, several months apart, in increasing doses, was remarkably helpful in mostly stereotypically hard-to-describe ways, but the most obvious was making it blindingly obvious that my intellectual understanding of the situation was not the same as processing it emotionally. You might point out that anyone who lives near Johns Hopkins or other universities/hospitals conducting such research could check to see if they are accepting applications to participate in studies
- Minor point: regimens 3A and 3B do not list energy/time budget, but I would guess it is "high" after the low and medium above
This is a lot of hard-earned wisdom right here, well said. Especially that intellectual understanding does not equal working things through, that our loved ones can sometimes see better than we can that something worrisome has settled in, and that radically lowering (or expanding) notions of what "counts" is really important.
Thank you for a wonderful summary and helpfully curated literature links!
I think the structure of the piece is excellent, and flows logically. It is indeed a difficult read, particularly for a depressed individual, but the subject is complex. I think it would be a mistake to dumb it down.
I love that you love tricyclics and MAOI! These agents are woefully underutilized.
It is my conviction that TCA are superior to all post prozac antidepressants for the treatment of panic attacks, and for that reason should be considered a first line agent for patients with both panic disorder and depression. Alas, I have only anecdotal evidence to support this assertion.
A related point, I would suggest you consider distinguishing panic from anxiety disorders in general.
It occurs to me this would be a great resource for concerned family and friends. Perhaps adding some links to resources, as well as suggestions on how to deal with a depressive in one's midst, might be a boon.
Other treatments not mentioned which have at least single or even multiple case report level citations in the literature include:
Modafinil augmentation
Core body temperature elevation
Augmentation with anti-inflammatory agents (which leads into the novel area of research of depression as an autoimmune disorder).
low dose buprenorphine
Your work on this constitutes a great service, potentially helpful or even life changing to many. Thanks and praise are due you.
The first time you mention omega-3s, you say "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."
However, the second time, you link to vegan and nonvegan capsules (which it looks totally reasonable to get 2g/day from), and describe "one pill/day [as] being a low dose and two/day [as] being higher" for the nonvegan option (whose pills are 605mg each - the label says 1210mg/serving, but a serving is 2 pills).
1.1 and 1.2.1: Are “depression”s associated with stressors and “depression”s not associated with stressors a single psychopathology or two (or more?) psychopathologies with similar symptoms? If a patient with psychological and/or physiological stressors is less likely to respond to medication, does that suggest the latter?
My bet is that there are multiple pathways to a set of symptoms that we call depression. And severity also alters what it looks like and how effective meds will be (more severe; more likely meds will help).
Meds to help people w/very good reasons to be depressed; I've commented on this somewhere. I wonder if there's a way to search the thread ....
In the business of prescribing different kinds of physiotherapy and doing some manual therapy myself I had to get to terms with classical massage treatment. Many people with pain issues wanted it prescribed and the insurances in Germany preferred active physiotherapy a lot. For many orthopaedic problems there are much more efficient hands-on therapy choices. The evidence said there was one sound indication for classical massage treatment: depression. Last time I checked, that hadn't changed. From an evolutionary perspective it makes sense to me. Other social primates fumble each other most of the time and those that get fumbled most happen to be the healthiest overall. They also happen to be highest in their hierarchies which may not be beside the point.
Anyway, if my schedule of training, meditation, work, personal encounters and beer should leave me too unhappy to bear it, I would get a lot of massages before taking any drug that hasn't been around before the industrial revolution.
1. Consider turning your list items into an actual list format, and bolding the list item itself that you're describing (e.g. the drug name in the drug list, the supplement in the supplement list, ...), that should make it easier to resume reading in case one is dragged away from reading for any reason.
2. I'd personally recommend people with access to a doctor should check themselves for deficiencies before taking anti-depressants. My B12 deficiency that I keep harping on was one that nearly went undiagnosed to terrible effect, because no one thought someone under 35 years of age who wasn't vegetarian/vegan would have it, and I didn't have a corresponding folic acid deficiency, so the symptoms were masked. Meanwhile I was gradually getting dementia. I was very, very miserable, despite somehow mustering up the desperate energy to rearrange almost everything about my life (it was so, so hard - and it definitely had large payoffs, but the largest chunk was just the deficiency).
(1) In 2.3, after you recommend ECT after your third-line options, put a "(see section X.Y.Z below)" call-ahead. Reading it, I was wondering whether you were going to go into more detail on it. You did, but not until a couple sections later and if I was cherry-picking a section to read I might miss it.
(2) In 2.6, add the doctor access and "high time/energy budget" to 3A and 3B. Sounds dumb but my brain wants it there for completeness.
I found it a good read at the right level for me and my bubble (mostly grad students). FWIW, if you end up making a less vocab-heavy version as some commenters mentioned, could you keep this one somewhere too? I feel like I know people who will be skeptical of any depression description that *doesn't* describe it at the level you're doing.
Nowadays I can still feel bad, or lethargic or something, but I hardly ever feel *guilt* for things I consider outside my control, like not meeting my own or anyone else's standards during moments of illness or fatigue.
For a fair-minded and fairly brief discussion of the history of electroconvulsive therapy that doesn't take sides, I would recommend Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky. It's a psychiatric history book that doesn't portray psychiatrists as moustache-twirling villains!
2.1.2.1 Spelling: change refridgerator to refrigerator
2.1.5 double word: change enough enough to enough
Overall I think you struck your desired balance of pointing out good studies, anecdotes and your personal opinion.
You don’t mention postpartum depression at all. Even if this is a whole other subject it deserves a mention.
Section 2.3
It’s a good no nonsense overview of medications and what you recommend in your practice.
I think you should add a comment on the time that is needed for “trying” antidepressants, i.e. how long they need to be taken to determine that they work, weaning up, wean off period and then another wean on period, large ballpark is fine. This may fit well when you mention first, second, third-line strategies, etc. or more specifically stated in section 2.6 (instead of gleaned from the scenarios) or 2.7 and putting a reference to that section in 2.3.
You gave time commitment figures for the ECT and TMS, which was very helpful. I’m currently in this process and have been for 10 months. It's very long and frustrating. When deciding to start medication, I found it difficult to get a straight answer from my psychiatrist(s) on what to expect. My guess is that they didn’t want to make any promises so I wouldn’t get disappointed. I wanted best case and worst case scenarios so I could measure my expectations. I had no problem with the caveat that we don’t know because every person is different, but only being told let's give it 2-3 weeks before we make a call was frustrating. It’s a constant struggle to continue to fight the depression. Having realistic expectations for how long finding the right medicine could take would have been helpful. Depending on your audience, this information may not be needed. My experience and those of my peers (20-30s year olds in the biological research arena) and any family member I have discussed this with, antidepressants are scary and we don’t know much about them, especially real world practice (like 2.7, I really liked that section). Setting these expectations correctly from the beginning goes a long way.
And time frames for therapy as well! If someone is attending regularly and participating as suggested (ie doing homework for CBT, trying new ways to deal with people in interpersonal therapy ....), they should START to experience improvement within 3 to 4 months. If there is no noticeable change for the better within 6 months, it's time to change approaches and/or change therapists and/or add medication to therapy.
And if the person is so depressed that can't do what therapy suggests, even when goals are realistic (ie, doing a little bit more than you're doing now, the re-evaluating that if it's too hard to do ...), then also time to consider a different type of therapy or adding medication/changing medication.
Scott, because you recommended magic mushrooms, I think you should also recommend LSD. I became quite depressed over the course of the pandemic and ended up reduced to staying in bed 80% of the day and constantly heavily drinking. I read your post on depression as an attractor state, then resolved to take acid and instantly adopt a bunch of lifestyle changes. Within a day I returned to something approximating my pre-pandemic self and started cleaning up all the life problems I created by being too depressed to do anything for six months. I cannot stress how great it was enough. It was like the acid gave me the tool box to just delete depressive thought patterns from my brain.
There is one question which is extremely conspicuous by its absence:
Should I try to treat my depression at all?
Seriously, treatments for depression are horrifically expensive, and not just financially. Therapy will cost you thousands of dollars and tens or hundreds of hours of your life. Anti-depressants will kill your sex life, make you fat and unhealthy and disrupt your sleep. Exercise and diet changes may be generally good, but you already knew that before you were depressed and didn't do anything about it then.
There is in fact another option: do nothing. Sometimes this even works and the depression resolves itself spontaneously.
It usually does resolve itself spontaneously, mean duration is around 6 months for a first or second episode. BUT there is often a huge price to pay in the meantime/as a consequence. Deterioration in interpersonal relationships, looking incompetent at work, flunking important courses/a whole semester ......
I usually tell people to give it their best efforts in self-care and seeking extra support from those who are about them. If they're heading past a month or 6 weeks without improvement, time to get help.
And of course 6 months is an average; often it lasts longer, or the consequences perpetuate the depression ...... And of course, if there IS something that will help and you can access it, it's a good general rule to reduce suffering. Being even moderately depressed is extremely painful.
I'm not arguing for it as the best option, certainly not for everybody, but it is an option.
The reason for pointing this out is that there is a fairly general bias in medicine towards treatment, any treatment that is not no treatment. Regardless of whether the treatment is a net benefit, we must do something to treat! Sometimes this is justified, like, "left untreated, this kind of cancer will always spread and kill you." Many times, it is not.
In the case of depression, do-not-treat is an option worthy of serious consideration, particularly given the side effects of the most common medications. The above presentation of depression does not even mention it, without justification.
That's why I don't like that many MDs default to 'oh, you're depressed! Here, take this medication ...' without even discussing other options with patients. While improved self-care and support-seeking and psychotherapy are not always benign, they mostly are, and often very helpful with few undesired side effects.
Here in Canada there has been a big problem with availability of non-medication options for anyone not able to pay for private care; not only not easy enough to access, but also big variability of what people can get, from province to province and from urban to rural and remote regions. Provincial gov'ts (responsible for health care) are starting to smarten up. Mostly because every $ spent on therapy and other supports saves them multiple $s elsewhere in the health system, but hey! We'll take it!
If you can still function and can handle the level of unhappiness or numbness or "everything is grey, I used to enjoy doing this thing but now I can't do it anymore", then sure, let it be. You can get used to feeling horrible all the time. People around you will get used to the new you or drop you - you're not the spouse or partner they fell in love with or the friend they used to have good times with anymore, they're not obligated to stick around the dull, silent, zombie.
Depends what you want out of life. If you can stick with several years of being like this, go ahead. Maybe you will decide you hate feeling this way and want to break out of it, maybe you'll just go on that way.
If people do want to change, Scott's advice is generally good.
This is a beautifully comprehensive, well-written, and helpful summary. I know some people who will benefit from this, so much appreciation for the time and energy and care that went into it. Since you asked for comments, I have a very few:
You call synapses "wires." Can you rephrase this to emphasize that they are junctions, connections? It probably doesn't matter to most people, but it reads weird to me.
You refer to a few amino acids as "chemicals" and I think it might not be bad to indicate that they are naturally-occuring amino acids, a regular part of the diet anyway, so you're not introducing something *new* to your body chemistry. That might matter to some people (it would to me, for example). And for those people who prefer to get it in a more natural way, they can go look up in what foods you could get extra tryptophan, for example.
In your discussion of CBT, and maybe therapy generally, one aspect I didn't really see covered quite as much as might be helpful in some cases is the degree of disordered thinking that is part of depression. One might think this is one of the foundations of the idea that CBT (or therapy) can help: that it may be possible by conscious effort to retrain your mind to have different habits of thought, which can help, on the grounds that some aspect of depression is misinterpretation of experience, i.e. a cognitive failure.
The reason I mention this is that I have known people who see therapy as just a mission of discovery. If I discover my mother was cold to me from ages 1-3 because of blah blah that was going on in her own life -- hey presto! the depression will go away as soon as I have this insight (and if it doesn't, that means I need some more insights -- different therapist, or another book from a best-selling author). I feel like the idea that discovery is not enough by itself, that there is work to be done to retrain your thinking patterns also, might be helpful to emphasize a little more in the context of discussion therapy. You certainly do mention it at various places, but it doesn't seem as connected to the therapy option as might be helpful, especially to people hoping that if they go to the therapist and just listen attentively, he's going to give them some explosive insight that will Fix Everything shazam -- and if he doesn't, he's a terrible therapist and/or therapy is useless.
Obviously I'm thinking of people who do not yet have a grip on their depression, and are not right now under the care of a good psychiatrist who would make all this clear -- but I am assuming these are among the people you most want to reach and help.
I found the introduction of attractors a bit weird, since they pop in but do not inform the rest of the discussion, and unless you are interested in signaling to physicists or mathematicians that you grok them it doesn't seem to do a lot of good. I wonder if you could use some more accessible analogy, like a pit with slippery sides, to emphasize (if this is what you're doing) that sometimes it's 2 steps forward 1 back, that is, that recovery from depression may not be a smooth path -- there will be setbacks, which should not be mistaken for complete failure.
Weird point but while I love the term "priors," I don't think it's gone mainstream. Meaning, I'm not sure the majority of normies (including depressed normies) would natively understand what priors were unless you explained it upon first use.
I'd add two things I think are important, and relevant enough to enough people to be worth including;
- New or greatly increased irritability and/or agitation can also indicate depression (more commonly seen in men, and probably one of the reasons men are less often diagnosed with depression).
- When depressed and considering/seeking therapy, it can be very helpful to consider whether this depression appears to be dominated by negative thinking, or by distress over interpersonal relationships (family, romantic/sexual, friendships, at work ....). If the thinking, then CBT will most likely be helpful. If relationships, interpersonal therapies and/or insight-oriented therapies may be most helpful. We can't directly change the people around us, but we can change how we deal with them, which can lead to improved relationships, or less distress in non-improved relationships, or more ease at getting out of/away from distressing relationships. HOWEVER, interpersonal/insight therapies are harder to learn to do, so getting a recommendation and/or talking to several therapists before deciding and/or looking for a therapist with a higher level of training becomes more important. BTW, the result of the therapy (and perhaps the source of its efficacy) may be that the person then manages to implement Scott's recommendation of changing the life circumstances that are making the person unhappy; this is often very hard to decide on and carry out!
I thought it was engaging and helpful. I especially liked the Mediterranean diet chart, links to specific supplements, and other concrete things like that. I often become paralyzed by trying to optimize, or mired in product comparison, so I appreciate how actionable this is.
I think you should add (maybe after detailing symptoms of depression) that if you think something might be physically wrong with you but your doctors keep telling you that you're depressed, document your symptoms and seek additional opinions. Many people with less common conditions spend years misdiagnosed or undiagnosed and being brushed off with a depression diagnosis is common. I eventually turned out to have ankylosing spondylitis, and Enbrel was on another planet, effectiveness-wise, from bupropion, even though bupropion gave me the energy and ... I don't know, cheery-optimism-ness? ... to push through a few years of pain and fatigue which is not nothing! But not an ideal replacement for accurate diagnosis/treatment.
Furthermore, I can tell you from personal experience, once that first diagnosis of depression or anxiety is in your chart, there's no limit to what symptoms some doctors will attribute to it. I once went to the ER because I couldn't catch my breath, felt like there was something in my throat blocking air, and was coughing up dark red chunky stuff (sorry for the image.) I had been sick with a cold for awhile, had laryngitis, and informed them that I was on immunosuppressant drugs. They say, oh I see you have anxiety, do you get panic attacks a lot? I say no, and I don't feel panicked, just concerned about this blood I keep coughing up. They spent an hour having me to do breathing/calming exercises, somewhat reluctantly got a chest x-ray and then said oh, huh, you have pneumonia. Which did not surprise me, because I was *coughing up blood.*
I will say that when I was actually definitely depressed, I did an online CBT workbook called MoodGym (don't know if it still exists). I thought it was dumb, expected it to not work, and felt stupid the whole time I did it but actually it seemed to work a lot. So on the paraphrased grounds that effective treatment is that which, when you don't believe in it, works anyway, I give CBT high marks!
My biggest piece of advice to someone depressed or otherwise ill in a way that makes you tired/forgetful/struggling to accomplish things is that if you have the option, ask someone else to handle the doctor-finding/insurance-calling/form-filing stuff. It's too easy to hit snags, run out of energy, and just end up delaying treatment for so long but it's insidious because it seems like it should be easy, like you shouldn't need help, you'll just do it tomorrow. If a partner/family member/friend is willing to help in that way, it can make a big difference.
"They spent an hour having me to do breathing/calming exercises, somewhat reluctantly got a chest x-ray and then said oh, huh, you have pneumonia. Which did not surprise me, because I was *coughing up blood.*"
That is the part that constantly amazes me. You show up at the hospital with definite, recognisable symptoms - it's not just "uh I feel a bit wonky", your pulse rate is off the wall or you are literally blue in the lips or you are crying with pain, and you get handed two paracetamol and are told "go home and calm down".
I was in the same boat - luckily, not pneumonia, but it wasn't until the chest x-ray that the doctors did go "oh, you have fluid in the lungs; turns out you have a respiratory infection, here's a prescription for antibiotics" where up until that they had been "just go home and calm down".
The irony was that the ambulance guys (I had to call an ambulance to get me to hospital) had told me, on the drive to hospital, "oh yeah, sounds like a respiratory infection, that's why you have [these particular symptoms]". Had they been the ones in charge, I'd have been turned around in about fifteen minutes; with the doctors, it took about two hours of cooling my heels until THE OBJECTIVE EVIDENCE OF THE X-RAY and not, you know, the patient complaining of elevated heart rate and inability to breathe, convinced them otherwise 🙄
As someone who has worked extremely hard to make lifestyle changes to fight depression and PTSD, I liked that you did not overemphasize medication compared to lifestyle changes. I think people too often will self-describe as having genetic depression to avoid having to do the work to fix their problems or to validate their difficulties. I think also there is a trend for people to try to get a diagnosis of something they consider more genetic than depression for a similar reason. People often fake/overexaggerate PTSD or bipolar (especially bipolar II) to make their problems seem more justified, even though depression itself is difficult enough.
It's sort of a catch 22 .. life style changes are hard, they require substantial willpower and dedication, its hard enough for "normal" people. most people i know that suffer from depression have extreme difficulties in exactly these areas (including me some years ago).
So yeah, i know it works, i was able to change my life in a very fundamental way (i stopped drinking, "dry" since 4 years now, i dropped 40kg, started working out, fundamentally changed my diet, I did a real u-turn), but i also know its hard. I'm sure there are some that use genetics as a cheap excuse, but after all .. some people are weak, and to change your life you have to be strong.
RE: Treatment algorithms & medication: I would suggest adding a bit on what first, second and third line strategies entails. For example, the different lines represent a gradual decrease in common usage and/or proven effectiveness or an increase in potential risks. My reasoning is that some readers may think that the third line are the 'big guns' and jump straight to those, especially medications that could be obtained without the potentially-threatening step of consulting a doctor.
Isn't ability to form synapses directly linked to intelligence and cognitive abilities? Does depression make people underperform on IQ test for neurological reasons?
Nope, they underperform because their concentration is terrible and their memory is not great, especially in severe depression. It's not primarily emotional; people who are extremely upset or unhappy can still do as fine as they normally would on IQ and other neuropsych testing.
I'm not a psychiatrist, nor do I have depression, so I'll only review for style and clarity.
In general, I think this writeup of depression is clear and informative. It has succinct summaries of the state of the field, and simple, concrete suggestions that people can follow. I like the Q&A organization because depressed people with no motivation probably find a wall of text more intimidating than ordinary people, who already hate reading walls of text.
Specific comments:
"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 is way too technical. There are intuitive ways to explain this concept that don't require an advanced education in chaos theory.
"(my third- tier suggestions weren’t studied, because the researchers were cowards)."
Your ACX readers know you're being light-hearted, but your first-time patients might not, and might think you're being very unprofessional in accusing researchers of cowardice for not following your suggestions. I think you should remove all instances of "coward" or "cowardice" except when you're describing yourself.
Regimen 3A/3B: you forgot to say who these regimens apply to.
I generally thought it was excellent (for an audience with sufficient reading comprehension skills) but the "coward" bit really stuck out to me as well -- it's probably both unhelpful and off-putting to tell depressed people that their psychiatrist is a coward.
This article is superb in many ways, but the main reason I feel compelled to contribute to the discussion is that I strenuously disagree with the comments suggesting an excess of academic language and complex ideas. I have two main objections to this point of view.
Firstly, I strongly believe that bridging the gap between scientific research and public discourse is crucial, and I think you strike a good balance here. But there's another advantage to disseminating these complex ideas which is less frequently remarked upon. People respond to models of depression that for whatever reason connect with them personally and give structure to their experience. Sometimes this is pernicious, because it may account for the effectiveness of pseudoscientific treatment. But it can be extremely useful, and the more such models that are out there, the better. For example, the section on depression as an attractor state in a dynamical system was fascinating, and I'd very much like to know more about it.
Secondly, there is a dearth of resources on depression for highly intelligent people, which makes it extraordinarily difficult to seek and consequently remain in treatment. Among other things, this is an enormous social problem, as the intellectual resources available to us as a society are eclipsed by depression in high IQ people. An opportunity to engage intellectually with the topic is extremely valuable, and I therefore emphatically discourage the removal of any academic material from this piece, on account of the rarity of the resource you've provided here.
This leads me to a final remark, and something I've often thought of. You mention that much of CBT "sounds and feels obvious", and that its advice has become cliched. This is a powerful deterrent, particularly to people with high IQ and major depression who are even more subject to the illusion of rationality that comes with the illness. And you are, of course, absolutely correct that the practice of CBT principles is what makes them useful. There has to be a better way to address resistance to it: a better way to communicate its advice and emphasize the necessity of building the routine.
In conclusion: if anything, I'd expand on the areas I've mentioned, perhaps with the addition of an acknowledgement that these ideas may be new and difficult, if you feel that the comments on the piece being too jargon-y are justified.
I agree about keeping this piece at an intelligent reading level. As I've mentioned, a lot of patients have to "dumb themselves down" when going to the doctor, particularly consultants or specialists (who seem to take it as a personal challenge and affront if you speak to them on any level above "oh doctor I have a really bad pain in my tummy") so the estimation of 'what people can or will read' may not be at a true level.
I found the use of "coward" somewhat off-putting and in some instances unclear. I also wonder if it might not be triggering for some depressed patients in the same way that "worthless" or "weak" could be.
1. Some upfront, visually-oriented, exec summary or graphic would be helpful, especially if it provides 1-3 sentence answers to each of your questions.
2. Am curious about answers to the following questions --
a. "A loved one is depressed. What should I do?"
b. "I am >= 90th percentile depressed. At best, I can perhaps summon the energy to do exactly one, low-effort thing. The alternative is giving up. What is that one thing?"
My guess after reading is some version of -- call a hotline and get help. But that's an inference.
c. "Should I lose 10 pounds before everything else here?"
"Consider exercising more and adapting a modified Mediterranean diet."
Should this be "adopting a modified"?
Re: some illnesses cause depression, some others have mentioned low testosterone which is now being implicated in depression, especially for older men. Might be worth a mention.
Re: 1.1: Is depression caused by biochemistry or life events?
The attractor paragraph seems pretty impenetrable. I suppose it depends on your intended target audience whether it's actually illuminating at all.
"This is one reason I continue to wonder if the sense of accomplishment and getting outside is as important / more important than the exercise itself."
I'm inclined to also think that it's partly mindfulness at work. Exercise and stretching both require focusing in the here and now, which distracts from negative thought patterns.
"If you have zero willpower, not enough enough to be the seed for a tiny investment"
Duplicate "enough".
Re: omega-3 supplements
Perhaps it's better to recommend brands that have IFOS certification. Some consumer reports analyses found that many omega-3 supplements were poor in EPA and DHA, and many even had considerable contamination with heavy metals. The supplement industry is brutal.
Re: 2.6, good idea providing examples of specific regimens. I think people are generally better at generalizing from the specific, rather than deriving a specific instance after learning a general rule. A set of mashups of your suggestions should give a good feel for how recommendations should be applied and how they interact.
Bit late but "I think it’s barely worth clearing up confusion between depression and anxiety." in section 1.2.1 and "Second, make sure your depression isn’t caused by some other issue like insomnia, drug abuse, anxiety, etc." as a step in 2.6 seem to me to at least be slightly confusing, as the first seems to suggest you should go right ahead and try depression-related treatment if you might have anxiety-depression but the second seems to suggest you ought not to do that.
I'm currently on Wellbutrin, 450 mg per day. I started on 150 and worked up to 450 over two weeks. My psychologist says this is a very heavy dose, but apparently my case warranted it.
I agree with other responders that this guide is really, really useful.
Adding more information about the interaction of other disorders with depression could be really interesting. As I read comments, I see people interpreting their "depression" symptoms in the context of symptoms of (possibly subclinical) other things. Since, as you state, depression-anxiety is a common pair, a section like "if you have these situations then you may be dealing with depression-anxiety" or "if you have these situations you may be dealing with depression-ADHD" et cetera could be useful for people who might not recognize themselves in the symptoms otherwise. For example the "freeze" state which comes up, in which the anxiety "oh no" creates a feedback loop with the depression "everything is bad" and makes it much more difficult to either calm down and change perspective (overcome the anxiety to address the depression) or cheer up in order to do relaxation and calm down (overcome the depression in order to address the anxiety.) 800 mg of ibuprofen and a couple magnesiums on a situational basis have been useful to me for this. I was recently prescribed prednisone for a couple of days for something non-mental health and felt happier than I had in years, too bad it ended. I am also a big fan of the hydroxyzine/cetirizine medications, if I am jittery because I ate peanuts or drank coffee, it feels like everything is falling apart and life sucks, but no amount of thinking about it makes a difference, but the anxiety/allergy pills knock it out until my metabolism can clear the irritant. I was in my thirties before I noticed those food sensitivities and wasted a lot of time miserable.
The depression - ADHD feedback loop goes something like, what was I doing, oh dammit I can't put this together (feelings of worthlessness), nothing makes a difference, it will never work, things are getting worse, I'm incompetent and nothing I try works out right (forgetting in the middle of every self-help strategy), distraction and failure pinging back and forth. I think ADHD meds are the key out of that one. All of that will look like "depression" but the reader experiencing it might not recognize themselves.
Do ADHD versus PTSD next!
Also the posters who mention the "dual diagnosis" side of depression plus substance abuse or depression plus substance use have a good point. This is dated information but the stoners in my high school were pretty open about their self-medication and condemned the establishment as useless; these people were far easier to access than quality professional mental health care and while the DIY approach was admirable there was often at least one weird element about their self-medication. Supporting their healing journey felt about a millimeter away from enabling them checking out mentally. Fortunately with the advent of legalization in many places it now may become easier to address; yes, your level of use and strains of use appear to be helping your symptoms, or no, your use is numbing you out while restricting your ability to manage your situation.
How many drugs their friends do may actually have a significant effect on what steps someone takes first when they feel they have mental health concerns. People with good connections may start with high-quality weed and move on to microdosing, bypassing SSRIs entirely, feeling empowered the whole time. People with no or bad connections may be more likely to use booze, occasional low-quality weed and then wind up in "therapy," feeling confused. At that point they are reacting not only to their symptoms but to their past experiences of self-management that didn't work. Which door someone opens first will determine a lot about the subsequent experiences - also, how they react to hallucinogens if they use them - and addressing that would be interesting. I don't microdose but when I look back, the people who I knew who were for example on shrooms at school or tripped every weekend were more resilient longterm than the ones who were drinking and that was dependent on friendship group (may have been some self-selection). What the support network is makes a difference although at the time I think the drinkers were considered more responsible. I hope the medical establishment can assimilate this, I think ketamine is a start. I think people do lie to their doctors about drug use and these patterns exist but might be hard to find in research.
A humble request: Please provide links or write more about this statement: "several studies have found that therapy from a book, or off an app, or via some other kind of course, is just as effective as therapy from a professional therapist." Or maybe you did already at SSC? Any pointers you have would be much appreciated.
I somehow got linked back to your intellectual progress of the 2010s post and it includes this relevant paragraph:
I also spent a lot of time thinking about SSRIs in particular, especially Irving Kirsch (and others’) claim that they barely outperform placebo. I wrote up some preliminary results in SSRIs: Much More Than You Wanted To Know, but got increasingly concerned that this didn’t really address the crux of the issue, especially after Cipriani et al (covertly) confirmed Kirsch’s results (see Cipriani On Antidepressants). My thoughts evolved a little further with SSRIs: An Update and some of my Survey Results On SSRIs. But my most recent update actually hasn’t got written up yet – see the PANDA trial results for a preview of what will basically be “SSRIs work very well on some form of mental distress which is kind of, but not exactly, depression and anxiety”.
What is the form of mental distress SSRIs work very well on?
I wasn't very impressed with David Burns' _Feeling Good_. I thought his suggestions were not particularly good and reading it felt like interacting with someone who didn't know me, didn't actually care whether my bad feelings were reasonable or not, and was just spouting out random reassurances in hopes something would catch hold with me.
On the other hand, reading Martin Seligman's Learned Optimism helped me quite a bit. Seligman actually seemed to understand the specifics of my negative thinking, and was persuasive in suggesting those extremes of negative thinking were both inaccurate and, with effort, changeable.
I know Burns is the big name in CBT books, but to me he's a puffball. I'd encourage you to at least pay attention and see how much Burns actually helps people who try him compared to other do it yourself CBT resources.
Plus the 'Feeling Good' book is a brick, overwhelming to anyone who is moderately to severely depressed. Burns' '10 Days to Self-Esteem' workbook is actually much better, I think, for 'classic' CBT, although I have to strongly encourage people to get past the insulting and misleading title.
Anyway, I feel like this would benefit from simpler language in some places. Attractor states are not common knowledge, and the word modality is hardly used by anyone.
Also, this quite a long chunk of text. Might benefit from being split into multiple pages or otherwise made less intimidating / time-consuming. It's already organized in a way that ought to make that easy.
I found that Carlson's cod liver oil mixed with oatmeal worked well for me for both IBD and depression. It combines omega-3s with some vitamin D, essentially. Mixing oil with oatmeal slows down absorption of both the carbs and the fats.
Subclinical deficiencies of omega3s, vitamin D, Magnesium and Zinc are very common now.
The mod-med diet seems like it would prevent all that, but most people aren't on anything resembling the mod-med diet. Most people severely underestimate how horrible their diet is. Maybe a first line treatment should be a dietary audit.
Perhaps some discussion of things NOT to do, such as playing extremely intense video games like diablo 3 all day, causing prolonged elevation of cortisol levels that makes you physically ill + habituation to higher levels of dopamine which make you bored by normal productive activities. My first depressive episode may have been triggered by playing too much counterstrike deathmatch.
Speaking of what not to do, there are some interesting studies on excessive social media use making people depressed/anxious. A social media detox is another thing worth considering.
The 'basking in the sun with minimal clothes on' made me crack up! In most of Canada that is not an option for much of the year. Plus the sunlight is at an angle that reduces how helpful it is, from about mid-September to mid-April. Thank heavens for cheap therapy lights!
This is a great article, but I don’t really like any of the scenarios. All of them seem to be a mixture of ‘easy’ and ‘difficult’ at least in the way I would define ‘difficult’.
They seem to break down into 5 interventions that are cheap and easy to do, and then 3 others that are much more difficult.
I am not a doctor, but, if I was a patient, I would want to try all of the cheap and easy ones first, and only move on to the much more difficult ones if the cheap and easy ones don’t work— so, MY scenarios would be:
Scenario 1) Cheap and Easy— buy the four supplements recommended and the light therapy thing, and try just taking the supplements and turning on the light when you eat breakfast:
Big question on the cheap and easy interventions: is it OK to do this? to take all four supplements simultaneously? If it is, it seems like the easiest low energy low cost approach is to buy the light thing, and a bottle of each of the four supplements he recommends, and try doing the light therapy and taking all four of the supplements, at the dosage he recommends, as an experiment, for a month or two, until the supplements run out. If it helps a lot, you are done—buy more bottles of supplements, and, I guess, keep taking them, I guess, for 6 months or 2 years and then quit and see if the depression comes back. Although that is not 100% clear to me. Is the try it for 6 months/2 years recommendation specifically for the prescription meds only?
Taking all four supplements would be $2/day at the low dose, and $3.30/day at the high dose, see below. So, definitely, cheap and easy:
2) 100-300 mg of 5-HTTP. [start at 100 mg daily, then go up to 200 and finally 300 mg daily after a few weeks. ] $17 for 120 100mg tablets, so, 3 tablets a day, which works out to one bottle being a 40 days supply— works out to about 42 cents a day. https://www.amazon.com/NOW-Supplements-5-HTP-100-Capsules/dp/B0013OQI1W/
5) the light thing, $114 one time cost. Very cheap and very easy to incorporate into your life— just set it up on the table and turn it on while you are eating breakfast.
Much Harder:
If supplements and light therapy don’t work, you have to go onto the much harder changes, which is, lifestyle interventions, or therapy, or seeing a doctor. Not sure which of the three is hardest, but all or any of them seem much more difficult than just taking some pills every morning, and using the light for a half an hour a day in the morning.
Scenario 2) Lifestyle Interventions
6) Never eat candy or sodas. But what about fruit juice? jam or jelly? baked goods? I’d guess he’d recommend avoiding all baked goods, candy and soda— but what about orange juice? is that just as bad a sugary rush as soda? is jam on toast at breakfast just as bad as a cookie?
7) cut back on all fats (except olive oil apparently—the diet he recommends recommends a ½ cup (3 ounces) of olives a day!!)
8) try whole grain instead of regular bread
9) Go for a 20 minute walk a day (in the morning ?)
12) make a doctors appointment and try to talk them into checking your thyroid, and try to get them to give you a prescription for either escitalopram or bupropion.
So, I'm not a doctor at all, I have no expertise in the subject at all. This is just the order I would try things in, simply based on difficulty. Eating right, and getting more exercise, and going and seeing the doctor, and reading books are all hard things--both to start doing, and to keep doing-- taking some pills and turning on a light is easy.
I would call myself in remission from a lifetime cyclical clinical depression affliction. I am pretty open about that and so people ask me questions a lot. The first observation I always offer is that it is very important to me to keep front of mind, and took a long time for me to recognize, that depression is a formidable, agile disease which operates with a quasi-Darwinian imperative to survive and dominate me. For me the major go-to of my depression has and I suspect will always be this mantra: “your a piece of shit, you have always felt the way you feel right now, you always will feel the way you feel right now; it is pointless to fight this.” For me, the best antidote to this has been journaling and/or using a mood tracking app. Being able to point to something concrete and to say to my depression "bullshit, it says right here that May 25 was a terrific day and I felt good about myself” was and is a really powerful spell breaker. I would add those tools to your discussion.
I thought one of your most important observations was that depression fundamentally impairs and degrades the perception of reality. That has certainly been my experience I see some tension between that foundational fact and the reliance in reality perception that is implicit in accepting the afflicted’s view of what are "depressing jobs, depressing relationships, and . . . depressing grad school programs.” In the recovery world we would call emphasis on changing such external factors as pulling a geographic. My own experience is that relying on my perceptions while depressed is a pretty rocky road which includes big let downs when changing the perceived causative external factors does not in fact improve the internal landscape. External changes are, I am sure we would agree, no substitute for the work of tackling depression in the various way you lay out.
Consider adding even more cautionary statements around the topic of changing what isn't broken. When you find an exercise/diet/pharmacological solution that works (and I have thankfully) taking out the medicine piece is risky and needs to be done under very close supervision. My experience has been that these drugs have pretty long tails and half a dozen times over the last twenty tears I have lowered or eliminated doses, felt fine and then found myself re-shipwrecked on the rocks in a matter of weeks and genuinely befuddled as to how it happened.
Just reading this and seeing how many potential treatments exist made me feel better. I took the beck depression inventory last night and scored a 20, but today I feel good without really doing anything different.
I was delighted to see how forthright you were on lifestyle changes, and especially love this piece,
" The most common are depressing jobs, depressing relationships, and (surprisingly often) depressing grad school programs. Their first priority should be to escape the situation. "
I would beg that you add "conventional middle school and high school" to the list of the "most common" for which the first priority is escape. My sample size is biased, but for decades I've created small, highly personalized schools with significantly greater autonomy than conventional schools (think of the range between Montessori to self-directed education and unschooling). Over those decades I've seen many dozens of students who had been diagnosed with clinical depression and/or anxiety, often suicidal, who escape school-as-they-have-known-it and, within a few weeks or months become happy and well, drop their meds, and wonder why they had ever been forced to go to a school that made them miserable all day every day. Often these families had already spent plenty of money on therapists, psychiatrists, treatment centers, etc. with no positive outcome.
At a minimum, mental health professionals should encourage suffering teens and their parents to consider alternatives to traditional schooling whenever possible.
While not explicitly related to depression, this Yale study is worth noticing,
"In a nationwide survey of 21,678 U.S. high school students, researchers from the Yale Center for Emotional Intelligence and the Yale Child Study Center found that nearly 75% of the students’ self-reported feelings related to school were negative."
"► We document a large decrease in youth suicide in during summer. ► Adults from a slightly older age ranges exhibit no summer decrease in suicide. ► The summer decline in youth suicide is not explained by weather, unemployment, or SAD. ► The increase rate of youth suicide during non-summer months aligns with school calendar. ► That increase may be indicative of broader stress experienced by youth in school."
1. I think that you may underestimate the biological effects of exercising. I agree that other factors are also important and might be even more important, but you are framing it in a way that sounds almost like "exercise is good but it is not really better than doing something else".
2. Maybe you could add more medication options. For example, MAO-B inhibitors such as Selegiline have a lot of benefits of MAO inhibitors without strict diet and other requirements. The downside is that it can start inhibiting MAO-A as well if you take too much and "too much" is different for different people.
Also, Pregabalin works well for some people and in my opinion, has a good risk profile. There
is some evidence that it makes you dumber meaning worse performance on a wide array of cognitive tasks but this effect is insignificant and probably reversible ("reversible" is a bit speculative though)
Also, I endorse Tianeptine. You might want to consider Amineptine as well. And if you are going to this "grey area" territory, Phenibut works spectacularly for some users. And baclofen is also pretty good.
Probably you know more than me about all these medications and already considered them and judged against them, but just in case something avoided your attention.
Scott already covered Phenibut in his article about gabapentinoids on SSC - it's a too problematic of a substance to just include it without a vast list of warnings, so no wonder it was not included here.
“Set yourself a regular sleep/wake schedule and stick to it. Choose a time of day and go on a 20 minute walk every day. Cut all soda, candy, and fried food out of your diet.”
- I think this should be included in all of the treatment protocols. At bare minimum certainly the last line
One additional thought SA. In the COVID suicide you wrote with your hallmark clarity that: "Okay, or it could be that there are two kinds of depression—the kind where you have some kind of stable predisposition to depression, and the kind where you’re upset because a hurricane just destroyed your city." This keyed me in to something that came out of a discussion of your treatise with my shrink -- in reality should it be split into two first-order sections -- depression as output/symptom and depression as input/disease?
- wouldn't RIMAs be the obvious (and underused) alternative to MAOIs? I understand they are basically second generation MAOIs, without death-by-cheese.
- physical illness/disability is a common cause of depression and a particularly nasty one, since you cannot "get away" from your broken body. Close to 100% of depression advice tells you to exercise, which you can't, and hearing that again and again makes you more depressed, to the point that seeking out advice for depression on the internet feels like twisting the knife and you start avoiding it. Adding a caveat, e.g. "exercise *if your health allows it*" would go a long way to soften the blow.
Is this supposed to targeted at scientists or at people who are depressed? The page starts with paragraphs upon paragraphs of technical details and taxonomy before anything manifests which would encourage a depressed reader to read on.
Maybe have some disclaimer at the top that this is for people who have a technical rather than personal interest in depression.
About psilocybin: It's illegal in the US and UK but not in the Netherlands and some parts of the Caribbean. There are fairly expensive psilocybin retreats in those places, but at least in the Netherlands you can also do a more basic trip-sitting arrangement. I wanted to try psilocybin for depression but was pretty risk-averse and didn't want to break the law or work out how to get a safe source of psilocybin. (The main danger in taking psilocybin is accidentally taking some other kind of mushroom that's not actually psilocybin.) I found a cheap flight to Amsterdam, bought some psilocybin in a shop, and stayed with an elderly hippie who trip-sat for me via a trip-sitting service I found online. It didn't make a noticeable difference to my depression, but it was an interesting and meaningful experience and was worth a try. I'd recommend that method to people who want to try psilocybin, don't know how to safely get it in their own country, and are particularly risk-averse.
About diagnosis: The only criteria I ever meet are low mood and thoughts of suicide. I think the DSM is just wrong about needing 4 symptoms in some cases, because even though I'm eating and sleeping fine, the whole "can't stop thinking about death" thing is a significant problem. To their credit, any provider I go to treats me for depression despite me not meeting DSM criteria.
About bupropion: another pro is that stimulates sex drive in some people, which might be welcome if your relationship has been suffering from depression and antidepressants.
Re iron supplements, you could mention getting one's ferritin levels checked after six months. It's rare, but too high a ferritin level (>200 ng/ml in women, 300 in men) can be a concern
Very thorough. One thing you hardly ever hear is: "By far the most powerful treatment for depression is GETTING AWAY FROM THE DEPRESSING THING." In my experience therapists never tell you this. It's beneath their dignity to tell you (for instance) that if you are frustrated at your job, probably you should just find a new job that's more rewarding and less frustrating. They didn't go to school for eight years to just give mundane advice! What they think they are good at is helping you make Herculean efforts to adjust to your cruddy situation rather than helping you make modest, constructive efforts to actually improve it. The problem is, the average person doesn't actually know that getting away from the depressing thing is really effective, and therapists are supposed to know this. (I would say it is depressing but that might get me into a bad attractor.) Another thing that lots of people don't know is that exercise is probably just one example of any kind of distracting and rewarding pastime, people think it is magically different from playing the piano or makings ships in bottles.
Re: the appropriate proportion of medical jargon for this sort of thing. I’m of the mind that the Scott’s of the world should use as much jargon as possible, just blow it out the top, and trust the audience to catch up. It shows respect for the intellect of the readership and is a realization that we’re all a Google away from a definition or scientific article. Once you start down the road of aiming for the least educated among a broad readership, you end up at the storied 8th grade level. This is different from a clinician tailoring his/her medical advice for a specific patient - in that case, the jargon should match the listener as best as possible.
The mathematical level needs mathematical notation and must not be ambiguous, because currently people like me who understand the larger point, won't read it carefully anyway [since it's just handwaving] and people who don't, need concrete structure or better yet links to where you explored all those ideas in depth before.
feedback on points 5 and 6:
"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 have offered 5 already, but...
the problem here is not that it's unfriendly towards people, who aren't deeply familiar with this kind of thinking.
The problem is, that it's so informal and sloppy, that people can't get to a deeper understanding from reading it carefully, even if they tried really hard.
consider how I read this:
At first, I just insta-read it and nodded "you're handwaiving at what I already read, thought about and liked". And you brought up "attractor state", "dynamical system", "inputs" on me, and I visualized a 3d graph.
Perhaps higher dimensionsional by adding colors, animation or vectors, if I really wanted to.
I think of "gradient descent", "slopes" and being trapped in a local maximium.
But then, I reread it after it was discussed in the comments and finally noticed:
you talk about "weight of the edges of the graph"!
Well, that can't be a function graph then, because you'd talk about slopes, not weights.
Weights are the little numbers over edges that connect vertices. Usually for cost or distance.
So we are doing weighted directed graph theory-style graphs.
Uhm... fair enough. Guess you could do that.
I don't even hate it, but then you don't define the vertices at all.
Implicitly perhaps in "either [life events or biochemical factors] or both of those can shift it into the new depressed attractor state".
I guess you mean V := {depression, life events, biochemical factors}?
And E = {(life events, depression, some_individual_number), ((biochemical factors, depression, some_other_individual_number)}.
"can shift into" makes no sense to me here.
Since a graph like that feels more static to me.
Well, I could mentally extend the graph into an automaton, petri-net or use a color-background to represent mood, but... I only came up with that idea, after I wrote the sentence two sentences ago.
Actually, you probably meant V = { depression, life_event_a, life_event_b, life_event_c,.... biochem_factor_a, biochem_factor_b, biochem_factor_c....}.
Okay, that graph is probably closer to what you meant.
But "either one or both" (and no concrete vertice-examples) really primed me to see that as three vertices, instead.
Which is why the graph theory graph interpretation was so implausibly poor, that it created a trapped prior of "function graph for dynamic system, makes sense, moving on" and blinded me to "edge of the weights".
Uhm... my reading process is mostly automated "scan for salient nouns and verbs and minimal connective structure, derive abstraction, if I understand it, skip to next parapragh".
"weighted edges" were suppressed as evidence, because it did not fit my assumption.
Same way, I wouldn't notice "Paris in the the springtime".
So the biggest issue with the article is its length. I didn't read it until now because I was intimidated by the length and I'm not depressed. (Though to be fair it turns out that the comments are the majority - the article is still a lot for a depressed person). That being said, it contains a lot of very good information and practical advice. I'd recommend putting each section under a text link, so people don't feel overwhelmed by the length and give up before they get to your advice.
I think the opening section 'The Short Version' contains too many long sentences with subsections and caveats. It doesn't feel comfortable to read or make me feel like I'm going to enjoy reading the rest of it. It seems written for a slate star audience and not your average depressed patient, or even my average patient (many of whom are slate star readers - thanks for the referrals).
I also disagree with your assessment of mirtazapine as a 'weak' antidepressant. I don't use it much because most people are put off by the risk of gaining weight, but I have been pleasantly surprised by its efficacy when I have prescribed it. I'm not sure it's less effective than SSRIs, and it has different side effect profile, so it is an important treatment option. I do think your description would put people off from trying it.
I am also surprised that you did not mention lamictal as a treatment option. While I do not usually prescribe lamictal as a primary antidepressant, it has been critical in the treatment of many depressed patients as an adjunct. I have effectively 'cured' at least 2 cases of chronic suicidality with lamictal+ therapy- I mean complete life transformation. It is also a great adjunct with stimulants for ADHD. If you are not prescribing this drug, you really need to be.
Excellent, complete, refreshingly open, candid overall! But the opening "big picture" or overview explaining "what is depression" could be improved. How? The overview as it stands begins by classifying depression as a "condition" - but a condition - of what ? It may be better to put "depression" in the context of normal mood variation, de-pathologizing low moods per se . "Depression" then would be an (abnormal, excessive, dysegulated, "stuck") low mood state - it's a condition of our "mood regulation system". Within normal ranges, we have low mood and elevated mood, anxious mood and calm mood ( putting moods as varying on two orthogonal axes, as behavioral biologists do when they theorize about animal moods - see Nettle and Bateson "The Evolutionary Origin of Mood and its Disorders" https://pubmed.ncbi.nlm.nih.gov/22975002/) and these moods are functional for us (and for many other animals) - they affect our interpretation of the world (the "priors", both in positive and negative directions) and reactions toward the world. One could add some evolutionary psychiatry thinking here on possible functions of (proportionate, normally responsive) depressed mood, and then, having put things in that context, say that (clinical ) depression is a condition where low mood gets excessive, "stuck", dysregulated, etc. I think this approach helps to reduce self-blame for feeling depressed even more than the "depression is a brain disorder" line of thinking.
Hey Scott, hopefully you have time to read this in the maelstrom of comments!
> "I once read an account by someone who said their mood was correlated with how many rooms they had been in that day."
I would really love to read this account. Could it be linked somewhere?
___
Also, since you asked for feedback, I tried to read this post when I was experiencing some milder depressive symptoms, and had to stop. I think this was an order issue. Personally, I felt having depression explained to me first was not very helpful.
My mood was very low, and the opening paragraph features, "Chronically depressed people live almost a decade less than non-depressed people", as well as a lot of information about how my brain wasn't working very well, which made me feel pretty powerless, and lowered my mood further!
I would maybe move the explanations of what is actually happening to the bottom, and start with stuff about diagnosis. That way people would probably be more likely to engage with the mechanics of depression when they're more capable of doing so.
Obviously this is just personal experience, it's possible that others would be comforted to know what is going on in the brain. (Although the chronic depression thing is definitely not comforting!)
"If you have zero willpower, not enough enough to be the seed for a tiny investment,"
"If you do want to be hungry and sleepy, maybe because your symptoms include insomnia and loss of appetite, mirtazapine is great. " <-- I'd switch the order here for parallel syntax
"Regimen 3A: As 2A above" / Regiments 3B: could list out the full "person with high time/energy" for parallel syntax
I think the paragraphs explaining ECT wouldn't do a very good job of convincing someone who is afraid of ECT because of all the horror stories to change their mind. Even though I already have an overall positive opinion about ECT, after reading this I feel like I would be a bit less willing to undertake it. I think the praragraphs need a lot less mentioning of how scary the treatment and it's side effects are. Also the memory side effects are quite rare with modern devices and proper dosing/stimulus titration and generally a lot less severe than you write here.
Overall a great guide to depression treatment. Thank you!
A friend noted that some of the claims like "most people know if they are depressed or not" do not cite any data that back them up (and they did not resonate with her experience). IE, the claims should be either backed up by some evidence or marked more clearly as personal impressions. Especially since these things could (I guess) vary a lot and cause some depressed people to go "I don't know feel like I know that I am depressed, so I am probably not".
As an anecdote, at some point I remember thinking "I am DEFINITELY not depressed, or nowhere near it". And after I filled some depression score sheet, the result was something like "borderline between mild and moderate depression".
Question: When talking about MAOIs you didn't mention Moclobemide? I haven't had a depressive episode in over 10 years (better job, more money, exercise, keeping busy). However, in the past, I had depressive episodes and needless to say I have tried both a variety of medications and therapies. The best antidepressant I found for me was Moclobemide - it worked on depression without the worries of interactions common to other MAOIs. The next closest for me was Nortriptyline which nearly worked as well but left me knocked out the next day and affected work performance.
I really enjoyed reading the piece though. No comments that haven't been already addressed but would reiterate the paragraph writing about dynamic attractor.
I understand Moclobemide isn't licenced for use in the U.S. Do you know what the reason it is? And do you know enough to include it in your article for those of us who aren't based in the US?
Hopefully, I will never have another depressive episode but if I do and I get to a point of needing medication I know it will be Moclobemide I will be asking for.
Perhaps this is something only a layman would say, but I object to the sentence asserting that depression has been cured in rats. The whole concept of animal models of depression was a new one for me, and I'm not saying that it hasn't validity. However, I don't think it's fair to frankly speak of "depression in rats." To the psychiatrist, depression is a set of symptoms, most of which require a self-aware patient who can report them. I'm pretty sure diagnosis requires talking with the patient. To most non-psychiatrists, it is an ill-defined but definitely subjective experience. Either way, it's not something that can be ascribed to a non-sentient animal. Calling rats depressed implies that it can be diagnosed objectively, and it kind of implies that the pathophysiology is known, both of which are, to my knowledge, incorrect. Better than "cures depression reliably when we do it to rats" would be "has a positive effect in animal models of depression." A quibble, perhaps, but I think it's significant.
I saw a claim once that people did an explicit study of placebo effect in treating depression and found it to be effective. Like, not a blind study; "hi we're studying the effects of the non-functional pills with no medication in them that are used in psych experiments", so patients were specifically *told* they were taking a placebo...
Dear Scott, as always I'm deeply pleased by your writing style and by the ease with which you summarize such a vast and complex subject.
I would suggest adding a section on meditation / mindfulness practices, as this is a hot topic and patients constantly ask / wonder about scientific bases for it's efficacy.
As an extra I was wondering if you would ever consider writing a similar resource about High-Risk mental states / "prodromal" phases, since in my opinion there is lots of information but not a lot of well-distilled knowledge surrounding the subject.
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
Also, I have taken this questionnaire when very depressed and even though I scored very highly I
1) did not believe in the validity of the questionnaire (despite the fact of clinical evidence of its legitimacy)
2) thought the answers were so transparent it would be impossible for a doctor to actually believe me, because if a person just wanted a diagnosis of depression (I have no idea why a non-depressed person would nefariously want this? Depression makes you worry about very stupid things) it was super clear what answers to give
3) I did not (and honestly still even while not depressed do not) trust my short term memory or sense of self enough to be confident in my answers
Last thought:
I know you touch on this, but I think it would be very helpful if you called out more explicitly the fact that therapy *doesn't* work for everyone, and it's fine if you hate it and want to persue medications.
I have had extremely negative experiences with therapy (maybe because I didn't go enough times? Maybe because my particular therapists are a bad match? Maybe because I'm an intellectual jerk? Maybe because I have a hard time trusting people I haven't known for a very long time? Maybe because I'm the baby of my extended family so I'm irrationally sensitive to feeling like I'm being condescended to and the nature of therapy is that it's a credentialed person telling you to do obvious things that sound obvious but are difficult to do).
But the way our culture talks about therapy it made me feel like a failure or like there was something fundamentally unfixable and wrong with me because I didn't like it. Or that I was just being a stupid-coward-quitter because I hated therapy and everyone else on earth apparently loves it
Yeah, I don't like that either, that notion that someone is deficient in some way because they didn't find therapy helpful. Also, there are an awful lot of not-so-great therapists out there.
I'm interested in whether the people who don't find therapy helpful or don't want to try therapy DO get benefit from the kind of apps or workbooks that are shown to be effective. Because that would suggest that the *skills* that one gets in therapy are effective but that the relational mode of delivery by a therapist serves as a kind of barrier. Some of the benefits of therapy are entirely relational, but some of them are learning skills, and it makes sense to me some people benefit from the skills but not from the relational part, which for them interferes with getting the skills.
Therapy is rarely described well (I think.) For people who are not accustomed to getting angry the tendency to stifle that will work against projecting the problem onto the therapist and solving it by proxy. For people who are too used to getting angry it will also work against the proxy solution. If not a problem proxy solution, therapy is a source of companionship and/or good advice, which both work against the proxy solution. There should be more ways to gain mental health skills. I don’t think I ever did CBT correctly. The times I approached correct I did not trust the therapist enough to inhabit the frustration/anger toward them. Your general remove/mistrust might indeed make traditional therapy turn into feeling like trying to find ways to piss you off! Probably hating it was exactly right, then you are expected to have the skill set for explaining your frustration to the therapist and the interest in doing so, then the therapist is supposed to notice you are doing that and respond in such a way that your relationship is deepened by the honesty rather than weakened.
The “guided confessional” therapy can be relieving but I think it might not be therapy per se.
I agree though. People sign up for therapy thinking it’s like finding an honest friend when it might not be that at all.
A therapist asked me, "do you think you deserve to be happy?" And my reaction was:
1) it's really annoying and condescending to ask me a question everyone on earth has agreed there is only one acceptable answer to. If you want an exchange this empty, email me a script, don't pretend to be asking me a question.
2) the premise of this question is stupid as people rarely get what they, "deserve" in life.
Another time a therapist literally told me, "it sounds like you know all the things you're supposed to do, you're just not doing them" and I was like, "yes no shit the solutions are very easy, it's the doing them that is hard" and got no productive advice from there.
But the absolute single worst therapy thing that they apparently drill into everyone's heads in "therapy 101" is the fucking, "keep a journal/log/list of everything you do for yourself no matter what it is, it could be brushing your teeth, taking a shower, etc to, 'build some positive momentum'"
1) if you have ever been severely depressed you will know that even if you gave this an earnest effort you will have days where all you can put is like, "drank glass of water" because you didn't even brush your teeth and just ordered garbage delivery food, and looking at that shit will make you feel a million times worse about yourself
2) I have never ever ever successfully been able to keep a journal on any subject for more than 2 consecutive days at any point in my life no matter how depressed or mentally healthy I was at the time. Asking me to journal all my activities, for an entire week, while I'm depressed feels roughly like a therapist saying, "okay, I'm going to give you a really easy depression fighting strategy that works for almost everyone: all you have to do is climb Mt. Kilimanjaro. Every week. For 6 months.
3) related to #2, the I'm just not gonna do the journal thing, maybe it's an ADHD/executive dysfunction thing. So all the assignment accomplishes is giving me another thing to feel guilty about and making it more likely I skip my next appointment because I don't want to deal with telling the therapist I didn't do my fucking homework.
Also like, my problems have never been particularly mysterious, and all the normal advice works totally fine, the issue when I'm depressed is I can't get myself to do any of the obvious things that work no matter how hard I try. IDK how I expect therapy to help me do the obvious things that work, but I am not convinced someone telling me, "you should do the obvious things that work" is more effective than a book telling me, "you should do obvious things that work."
At least with the book I can stip the part about the damn journal.
I hate it when people get bad therapy.
Good therapy should always be working with you to help figure out how you can start to do something that may help. It HAS to be individualized; journalling is not for everyone, NOTHING is for everyone. And re-calibrating every time what we've figured out to try doesn't work. W/o shame or blame.
OTH, when I've been doing that with a patient for multiple months and we're really getting nowhere, I make them go back to their MD to re-check all the physical stuff that might be causing or sustaining the depression, and then check all the rare stuff that might. And we consider meds or different types of meds.
meds have worked great for me, and thanks to an SNRI & a low dose of extended release adderall I feel like I have a good handle on my depression for the first time in ages. Obviously therapy is great and helps lots of people, but the way it gets talked about in popular culture really chafes me I guess.
I'm glad to hear you have found things that are working for you. Thanks for your post, made me grin. I think the world needs more honesty about experiences of therapy. How did you manage to get an SNRI? Did the doc suggest it or did you extract it out of them?
"A therapist asked me, "do you think you deserve to be happy?"
My goodness, everything you describe resonates so much with me! My answer to that would be "Well, I know the answer I'm *supposed* to give, i.e. 'Everyone deserves to be happy', and I even know the answer under the answer I'm *supposed* to give; viz, I say tearfully 'no, I don't deserve to be happy!' and then you fill me up with platitudes about why yes I do deserve to be happy because that is supposed to be the root of my problem - I don't feel deserving, but let's skip the bullshit.
No, I don't *deserve* to be happy. Nobody *deserves* to be happy. It's like grace: you can't earn it, you can't do a ton of good works, you can't keep a running list of "Why I've Been The Goodest Boy (or Girl)" in order to prove that you should get the Hollywood Happy Ending.
(People don't deserve to suffer, either, but sometimes they make choices for whatever reason that end in suffering, and you can forecast this - why else all the "don't smoke, don't drink, lose weight, exercise" advice trotted out by the medical profession?)
This is why the scene from "The West Wing" where President Bartlett does his 'non serviam' speech in front of a crucifix is full of shit. I'll give Aaron Sorkin a break, but Martin Sheen is Catholic, he should have known better. Bartlett trots out his "I've been The Goodest Boy for so long, I don't deserve bad things to happen to me" whinging in front of the crucified Christ, the prime Christian example of someone who Did Not Deserve This? Put it away, Jed, you had the seven fat years now welcome to the seven lean ones.
So being a Good Person doesn't mean I'll be happy. I can't work my way to happiness. Maybe winning the €10 million lottery will make me happy - or maybe it won't. There is no "deserving", there just is the reality of the world we live in: our biology, our environment, our circumstances, the people around us, natural and unnatural disasters, learning skills to cope with all the above."
Ditto the part with the journal: I have never been able to keep a diary, either, and whenever I've had to do one for school assignments or so forth, I end up writing a work of fiction to pretend I did all these interesting things because otherwise it would read *every single day* "Got up, went to school, came home, did my homework". And precisely as you say, the point about 'building positive momentum' where the therapist then goes "Well done, you brushed your teeth every day!" oh great, another thing to feel guilty about: this is something easy normal people do every single day and you, worthless loser, can't even manage this much?
Today is my birthday. Today is also when the depression, or mood swings, or whatever, kicked in for no particular reason (no, it being my birthday didn't trigger it, it's not A Significant Milestone, it's just like every other birthday in my entire life).
So I've ended up dumping the birthday cake and the flowers family members sent me into the bin. I've asked not to get any more such items. I want to get blind drunk. I also want to go back to bed (it's currently 2:30 p.m. over here) and go back to sleep for at least the next eight hours. Being alive hurts and I want it to end. (I can even pinpoint the location: at the very top of my breast bone. It hurts). I'm not going to self-harm (though I do sort of want to get a scissors or a knife and start scraping at my arm) and I'm not going to kill myself. I would, right now, really really like if I did go to sleep and never woke up again. I don't have any sedatives, hypnotics, or other medication, so don't worry there. I may get drunk enough to help fall deeply asleep. Maybe not, dunno.
Writing all that down in a journal under "Didn't do any of the housework I planned to do. Did get up to destroy stuff" is not going to help with "positive momentum". Talking to people is not an option because it will not help. Nothing helps except to wait it out.
Eventually it will pass. Eventually it will come back again. So it goes.
I have a theory that a major reward for abusers is seeing their victims be unhappy. Visible happiness gets punished.
If I'm right, it's unfortunate that the framing is "I deserve to be happy" when the actual issue is that whether happiness feels dangerous.
Overall this is excellent & I expect it will help me try to get treatment for my depression. Several comments:
⋅ I found a meta-analysis of controlled trials of therapies for self-control/self-motivation/mental 'energy' in particular at http://www.devcogneuro.com/Publications/J_of_DevCogNeuro_paper_in_press_2016.pdf , which concluded that there was little evidence that physical exercise by itself improved these & that improvements reported from some forms of exercise such as sports & martial arts were probably due to the mental component of the activities. Does this mean that exercise mainly helps with other aspects of depression than this, or that additional evidence that that study didn't consider contradicts its conclusions, or are they just studying something different?
⋅ In https://slatestarcodex.com/2014/06/16/things-that-sometimes-help-if-youre-depressed/ you recommended modafinil to treat some of the symptoms of depression, & based on what you've written here, if it works, I would expect it to improve self-confidence like behavioral activation does. However, I see that you have omitted it from this. Do you still think it is likely to help?
⋅ I agree with the other comments here that "Realistically, most people know if they’re depressed or not" is not always true. My depression began with anhedonia & problems with concentration & motivation, so I interpreted it as akrasia, followed by sadness about the effects of akrasia, rather than as a mental illness.
⋅ I also agree with the other comments saying that your paragraph on the dynamic system model of depression is too technical to be understood by most people. (I didn't fully understand it despite having read & understood your article explaining the idea several months ago.) The point it makes is important, but I think it would be better to explain it in a less technical way.
⋅ Regarding style: Your article is occasionally less formal than I would expect of this sort of article (e.g. "wearing rose-colored glasses and being a moron", "because the researchers were cowards"), but I'm not sure that's a bad thing: probably it makes the article more engaging to readers. Your clearly disclaimed descriptions of your personal expectations ("Secretly I suspect Zembrin probably works better than 5-HTP or St. John’s Wort, but there’s not enough evidence for me to recommend it", "I am positively predisposed to this substance because my girlfriend has used it successfully") may or may not be appropriate depending on how you intend to use this article: if it is meant primarily for your patients or prospective patients, these things are probably helpful in indicating your opinions/preferences to them, but if it's meant primarily for people looking for information on the internet, I'm not sure that they add much.
What if I suspect my depression is caused by an unshakeable belief that the world is shit and is almost certainly getting shitter?
A big part of many therapeutic treatments is figuring out which beliefs you have that are helping you lead a constructive, happy life vs. which ones are just digging you further into your own unhappiness. I'm no shrink, but I definitely know people who think this planet is a miserable crapsack, but they're not unhappy because the most important thing in their life is the work they try and do to improve it.
That said, if you want to be happier without changing anything about yourself or your beliefs, I hear nihilism and hedonism both pair pretty well with this particular outlook.
Oh this is a much better reply than the one I was trying to come up with. In general it seems to me having unshakeable beliefs is a recipe for suffering because one is likely to seek out evidence to confirm that bias.
Random hot take, regard with caution: My belief is that this only makes you feel bad because you cling to hope that you're wrong.
By letting losses be losses you regain the ability to be content. Terrible is always relative to the status quo, and clinging to a specific status quo won't help the world anyways.
Maybe it would have, back in the ancestral environment, when due to smaller tribe sizes your dissatisfaction would've been a much stronger driver of tribal policy.
Considering how much worse things were for your ancestors, perhaps it's still not so bad as to warrant long-term depression since they clearly managed. Glass half-full and all. Then again, maybe all of our ancestors were depressed too.
For stuff like fish oil and L-methylfolate, could a person just eat foods (like fish and leafy greens) instead of supplementing? Or would you not get high enough levels of folic acid from eating a bunch of peanuts and spinach?
This is undoubtedly amongst the best and most useful things I’ve ever read. I’m just grateful that such an amazing and helpful write up even exists. I’ll be forwarding this to a lot of my friends.
Also n=1 evidence: the claim about the Mediterranean diet is probably true. I’ve increased my consumption of fruits and vegetables, and I think it has helped my mental health a lot.
I'm a guy in his late 20s, and many of my friends have some kind of diagnosed mental illness, and maybe this is just a factor of my artsy fartsy social cohort, but they all went through a mid-20s period of That Time My Depression Collided With Financial Self-Sufficiency And Access To Self-Regulated Cannabis and/or Alcohol. And for some people this was easier, and for some it morphed into a serious dependency or a stint in rehab, and two people killed themselves over issues that the weed or booze probably exacerbated. So, maybe to include a small section on substance abuse - specifically the most garden variety options - is unnecessary, or assumes bad faith, but this has proven so common a battle among depressed/anxious people I know, that I figured I'd be remiss in not mentioning it.
I'm probably bipolar, but for a long time I thought it was depression, and the best description I ever heard of depression was: You have a machine inside your brain that ascribes meaning to things - it renders jokes funny and sunsets beautiful and experiences good or bad - and that meaning machine is broken. The important thing is that your brain starts to miss when certain things meant "hope" or "pleasure," and to have all of those experiences that mean nothing of course becomes exhausting, but that's separate from the "lots of sadness" description I frequently see. Thanks for writing this - I think it'll help people.
I second the comments elsethread saying that 1. this is fantastic...for Codex readers, but 2. some of the nerdier bits are likely to switch off the general public. Dumbing things down does suck, though, so...I don't know. Presumably maintaining separate pages for nerds and not-nerds is out of the question.
> Many psychiatrists refuse to prescribe this medication because they are cowards, and I don’t have a good solution to this.
I chuckled at this, but it did make me think of a (seemingly?) parallel line from the amphetamines post:
> If none of these work, a braver person than I am might try Desoxyn.
Of course, you didn't exclude yourself, so no foul.
Hrm. Actually, having browsed around the Lorien site for the first time, I think I've changed my mind about this. The other articles are written at a similar level, so it won't be out of place. They're a breath of fresh air, actually; it's like all the most useful bits of the "more than you wanted to know" posts in one place. It's hard to find articles on these subjects that are written to convey meaning, without dumbing-down or obstructive ass-covering.
I think I'll read the rest.
I don't understand how anhedonia differs from loss of interest in activities. I know that's not a list you made up, but perhaps your summary could be revised to make the distinction clearer.
Beyond that, I've always been interested in ECT as a one-stop solution, but I understood it was seldom practiced. Is it more common than I thought? Does insurance usually cover it? How expensive can I expect it to be?
Anhedonia - you do things you used to like, but you don't enjoy any of it.
Loss of interest - you don't want to do things, so you don't.
If you don't enjoy one thing you used to like, there might be a good reason for it.
If you don't enjoy anything at all, that's almost certainly some psychological problem.
Losing interest in some activities also sound normal if you find a replacement, but if you don't want to do anything at all, that's certainly a problem.
The former can lead to the latter, but not necessarily so.
Someone correct me if I got any of this wrong.
That makes sense, although the two are certainly easy to conflate from the inside.
In my mind, anhedonia and lack of motivation to do anything, even enjoyed until very recently, is what differentiates depression from unhappiness.
By analogy (but also by things I had while depressed),
anhedonia is when food stops having flavor, ie your favorite food tastes like chalk,
and loss of interest is when you either don't have an appetite OR you're hungry but not hungry enough to go to the bother of having to choose a food and prepare it and chew and swallow it (which feels exhausting and overwhelming)
I've spent a fair bit of my early life managing and trying to dissect the cause of my MDD/GAD, so I hope this might be useful to others. Apologies in advance if this is a bit haphazard, I've accumulated various niknaks of knowledge from my own experience and others, and don't think it could all fit in a comment.
(Quick fyi: I think your page is already very comprehensive as it is)
I'll first start with things that I think might be worth adding to your page, and then discuss what has personally benefited me the most:
- There appears to be a fairly robust link between depression and inflammation, which I'm sure you're aware of but you may want to mention. A lot of the therapeutic or preventative treatments have an anti-inflammatory effect, including SSRIs (and fish oil, and exercise).
+ There's a compelling narrative that one can draw around evolutionarily advantageous genes related to infection protection and those that are implicated in depression. (This is the most comprehensive discussion I've seen on this line of research and would recommend watching it if you haven't: https://www.youtube.com/watch?v=6DtJGJWjDys).
+ Dr Raison discusses sauna as a promising method with an anti-depressant effect, and various studies which show therapeutic effect.
+ Exercise induces an acute inflammatory response, which is then followed by an even more potent anti-inflammatory response, just from felt experience I think this is a likely mechanism.
- Studies on psilocybin have been overwhelmingly positive but primarily focussed on terminally ill patients until recently. Cathart-Harris et al's recent RCT of pscilocybin vs escitalopram on people with ordinary (I believe unipolar) depression have been very encouraging, and in particular on their secondary outcomes. I would check that out if you haven't already.
+ I also think there is a very compelling narrative that can be drawn around how this fits with predictive processing and the self. (I speculate about this here: https://umais.me/writing/the-anatomy-of-wellbeing/, also links to Cathart-Harris's REBUS paper on the differential effects of psychedelics on different layers in the heirarchy)
Now, for my own personal anecdotal experience:
- Anecdotally, (mindfulness) meditation can worsen neuroticism, or self-referential thinking if you're already in the midst of a depressive episode. I recall Jon-Kabatt Zin (founder of mindfulness based CBT) mention something similar in his book Full Catastrophe Living. (there are some reasons why I think this is the case).
+ However, not all meditation is the same in my experience. Metta (loving-kindness/compassion) is a type of meditation that I believe _can_ be hugely beneficial in the midst of an episode or during anhedonia. Neurotic and self-referential thinking is a major driver for most depression, and by explicitly focussing on the happiness of others you relax this tendency. I really can not recommend it enough.
- Historically whenever I've tried using fish oil during an episode it has worsened my mood. I've tried this a couple times and was always a little confused given that I expected a placebo effect at the very least. I've read some stuff that suggests it could be oxidation of the fish oil but I was never too convinced. The Raison interview elucidates a possible mechanism that could be the reason why, at one point he mentions the apparent contradictory effect of an anti-inflammatory given _after_ inducing a depressive episode vs as a preventative before. With the former reducing cognitive symptoms but not the latter. Perhaps fish oil works as a preventative treatment, but worsens mood when experiencing the inflammation of an acute depressive episode?
There's a lot more I want to say on the topic, but it's 2am here and in the interest of sleep I'll end by just listing interventions along with my own totally arbitrary effect sizes ratings out of 10:
medication (8), exercise (7), sleep (7), compassion meditation (6.75), diet (5)
Great recommendation for the methylfolate. I’ve heard really good things about Jarrow. If you are on a lower budget there is a Winco brand and lots of others. But the effectiveness at the dose varies directly with price (at least for my kid.) To get the same effect at half the price it was about twice the dose. So we would roll along at an affordable “okay.” As he grew he needed more to get the same effect. When he was finishing a jar every three days we tried a degreed psychiatrist, but there were weird side effects for some things including the SSRI so we stopped. Then in desperation I located some T3 thyroid and it did help. Now I just buy the bovine thyroid supplements which taste awful but help.
I used 5-HTP for a few months and it helped some although I now see I was not taking enough.
How about ibuprofen? Or prednisone?
In case that sounds like BS it addresses the chronic inflammation side of the illness.
Just want to put out a strong plug for Emsam: a patch version of an MAOI. It packs a bit less punch than the pills but still has quite good effects in a number of people, and crucially doesn't have significant amounts of the side effects that pill-based MAOIs have: there are effectively no documents cases of actual serious reactions from cheese/soy sauce/etc.
Thanks SBF!
In section 2.6, regimen 3a and 3b, you recommend reading "feeling great" and doing all of its exercises, but in section 2.2.2 you recommended "feeling good" and noted that you weren't familiar with the contents of "feeling great". Probably you mean to recommend the same text both times?
"Less-well-studed "
Less-well-studied
Separate comment on the lorienpsych site rather than the post: Your category pages (e.g. https://lorienpsych.com/category/conditions/) have a *lot* of wasted vertical space, so much so that it's not immediately obvious I'm looking at a list; on load I can only see a single item. Some of the culprits I found in CSS: a fixed height:500px assigned to .blog-card-inner; excessive fixed margin/padding on multiple items under .blog-card-group; absolute positioning on .blog-card-inner-inner (indirect issue, breaks when the height is corrected).
The general design of the category pages suggest they were built from a template intended for an image-centric blog frontpage, not a page index. It is probably better to fix that by using a more appropriate template than by hand-hacking the CSS.
(On the other hand, +9001 points for putting your nav bar on the side when the view is wide enough, and for *not* making the narrow-view top-bar obnoxiously sticky. It's nice to know that some web designer somewhere declines to commit that particular atrocity.)
I'm just grateful to be alive at a time when we get two amazing posts on consecutive days
Thanks for this! I enjoyed reading it, and as a family doctor will consider suggesting this read to (at least the more intellectually inclined of) my patients going through depression. Just a couple of suggestions - I haven't read all the comments so others might have mentioned already:
1. At least where I am in Canada, psychiatry access is sub-optimal and the number of patients who would probably benefit from seeing a psychiatrist is smaller than the number who can see a psychiatrist. We do a lot of primary care mental health. When I read, "If you’re not sure if you’re bipolar, talk to a psychiatrist about it before trying anything on this page," I thought, wait a second... as a family doctor I think I am generally fairly capable of screening for mania/hypomania, and if a patient who I am convinced does not have bipolar believes that they do (this is a non-negligible number of patients) and insists on talking to a psychiatrist before starting anything I recommend... the delay could extend their illness significantly. Maybe this is context dependent, but I would consider changing this to "discuss this with your doctor before trying anything on this page."
2. Is there a reason you don't go into specific light therapy recommendations for SAD? Obviously there's lots you could cover and don't need to, but I think the minutes/lux etc might be useful enough for people to know, to justify including.
3. It might be worth at least mentioning as a side comment that there are some potential downsides to psilocybin? Here they sound totally uncomplicatedly good aside from being illegal.
4. Just a thought in response to the comments about education level - I think it's fair and helpful for you to target a higher education/reading level than the average person, because there is already a reasonable amount of (admittedly, less comprehensive) reading material about depression available at a lower level to the average person. I personally find the part about attractor states to have the lowest helpfulness-to-complexity ratio so if you were going to get rid of one complex idea, I would vote for this one.
Thanks again.
My understanding is that light therapy is quite helpful, for many people, for almost any form of depression, not just SAD. Even bipolar depression - although then the person has to do the light therapy at lunch time instead of in the morning, to reduce the likelihood of triggering a manic/hypomanic episode.
I push this one bigtime, as it's quite easy to do and the lights have gotten really cheap.
So I'm not entirely sure what you're going for or who your patients are, but as a person who has been depressed in the past: I would not get through this. I would judge I am not currently depressed at the moment and I still gave up in the nutrition area.
For me when I am depressed, this would be both (a) way too much info, and (b) way too much hedging/inconclusive statements. Also, I don't know how educated your patients tend to be, but I would also judge this as written too highly for many--it assumes a lot of base info that I don't think is common knowledge.
I find concentration very, very difficult to maintain when depressed. While it may be useful/worthwhile to have the more in-depth info somewhere, it can't be the main page. Tell me what you want me to try. That's really all the info I can process. The links are good. I would prioritize having clear, precise, easy-to-follow directions for each point.
In more general terms: I have always found "additive" solutions more useful than "subtractive" solutions. Don't underestimate the positive emotional effects of "junk" food or other vices. Changing your entire diet might work, but I'm not going to do it and neither is anyone else I've ever known with depression (unless someone volunteers to be our cook). Start small: just add some carrots or something to the dinner you were already going to have. Don't join a gym, just watch some youtube aerobics videos, or take a walk around the block. The larger the ask (and remember, to a depressed person, things like "take a shower" can be monumentally massive asks) the less likely a depressed person is going to actually complete it.
Oh also: rule out other medical conditions.
My depression was mostly eliminated when I was diagnosed and treated for (actually rather severe) allergies that had an abnormal presentation and so were never noticed.
How were your allergies discovered?
You've reminded me of a time when I was depressed (couldn't sleep, was crying a lot) and it went away when I cleaned black mold out of a plumbing access.
A nurse got confused about my chart--she was reading it at the start of my appointment for a sinus infection, and said "you were just in for this yesterday!". Except the date of my previous appointment had been for a year and a day ago, and that led us to realizing that I was getting sinus infections like clockwork every year in mid-April. So allergy testing was recommended.
I had no typical symptoms of runny nose, cough, sneezing, itchy eyes, or whatever. My only symptoms were recurrent sinus infections, migraines, and depression. When I did the skin test at the allergist, I reacted to everything so severely that all the welts ran together and made a big red rash on my arm--but, because my body is just determined to be weird apparently, it didn't itch at all, to the allergist's amazement.
I am allergic to mold and have had similar experiences. I *hated* one of my jobs, to the point where I could barely make myself go to work. About a year into it, a whole team of construction crews tore the facade off the building, because water had been getting between the brick facade and the walls and there was mold growing everywhere. My feelings improved after that. And I had a serious relapse when I moved into my current house--about a year after we moved in, we discovered that there had been a slow leak in the pipes in the master bath and that there was a massive mold infestation in the walls and floors. Again things improved after that was remedied.
This is excellent. This is the most informative post on a medical subject I have ever read.
A question on your suggested regimens: The only cases in which you recommend the L-methylfolate is when the person is also taking escitalopram. You recommend 5-HTP as a stand alone supplement, or L-methylfolate plus escitalopram, but you never recommend L-methylfolate as a stand alone supplement, or ever recommend taking both L-methylfolate and 5-HTP together. Is there a reason for avoiding taking both L-methylfolate and 5-HTP? Is there a reason to not take L-methylfolate as a stand alone if you can’t get escitalopram?
In the comments, a lot of people panned the ‘depression is an attractor state’ paragraph. FWIW, I found it extremely helpful— it really clarified the entire discussion for me.
A few minor suggestions
— typo ‘Less-well-studed’ should be ‘Less-well-studied’
— I’d suggest capitalizing the ‘L’ in ‘l-methylfolate’, to reduce confusion. People who have already heard of it no doubt pattern match the ‘l’ in ‘l-methylfolate’ to the letter ‘L’, but first I thought it was the number ‘one’, and then I thought it was the letter ‘I’.
—another useful item would be a list of foods high in L-methylfolate. You say it is ‘common in various vegetables’, but it would be helpful to know how much of what I would have to eat everyday to get the equivalent of the 15 mg supplement.
— word order ‘I still cannot recommend it enough’ should be ‘still, I cannot recommend it enough’
—I would highly recommend moving the link to the page on light therapy up to the first or second time you mention it, rather than all the way down in section 2.5.
Tons of people ITT: "I enjoyed it, but who's your audience?"
Hmmm
> “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.”
For content like that, consider using sidebars that more technical readers can peruse but ordinary readers can skip over without affecting flow or comprehension.
These are mostly typos, and I'm not bothering to dedupe with other people, sorry.
The "attractor state in a dynamical system" paragraph could use a context/definition link. I know what you're talking about, but only from having read SSC/ACX.
"In a study in India" link spans too much text, and there is an extra comma at the beginning of the currently-linked text.
Add a period after "algae-derived version".
"Again, the most important answer" at the beginning of the exercise section doesn't seem quite parallel enough with the diet section to merit "again".
"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": "enough" is duplicated, and "medication give" doesn't agree.
I was hoping you'd say something about modafinil? There were a few interesting papers some years ago about them as therapies (particularly for atypical depression IIRC). My understanding from someone who tried to use it was that all normie psychiatrists laughed him out of the room asking for a script though. Do you have a strong opinion on it?
Consider adding untreated Celiac Disease as one of the diseases that can cause depression. I had no idea I had Celiac until I did a bunch of blood work trying to figure out why I might be depressed earlier this year. Turns out a gluten-free diet was basically all I needed!
I'm a mathematician, but I don't know what "attractor state in a dynamical system" means. I second others here: just scrap the "dynamical system" explanation, or rewrite it in layman terms.
This may be an edge case outside the scope of this article, or it may be helpful. I'm not sure, so I'm sharing.
I'm autistic (diagnosed with Asperger's back when it was still in the DSM), and have at various points also been diagnosed with MDD and GAD. If 1 out of ~50-80 people are autistic (estimates vary), and a substantial percentage of autistic people also experience depression (estimates of percentages vary), and something like 80% of autistic people don't have full time employment (which in the US is a prerequisite for most health insurance that isn't terrible)... I think we're a demographic worth considering, especially because a lot of the lifestyle-type changes don't work for us and we are more likely to have unusual side effects from medications (probably because of our neurological differences from allistic people).
For example, it's common advice (which you rightfully repeat) for depressed people to continue seeing friends, doing enjoyable activities, getting sunlight, etc. But for autistic people (or people with other disorders of sensory processing), these things can be overstimulating and make low mood (and its close friends, autistic meltdowns and shutdowns) worse.
Similarly, it can be helpful to take medications but (anecdotally) we seem to be more likely than allistic folks to get weird side effects to psychoactive substances. Do we just... Give up sooner on meds? Try more meds and suffer through the weird side effects until we find something that works well enough (which is what I did)? I genuinely am not sure.
Maybe the obvious advice is just "don't do things that make you feel worse." But it took me a long time to realize that forcing myself to do those supposedly-helpful things wasn't helping, and that it wasn't helping because I'm autistic. And I kept trying to do those things for a long time, because I take directions too literally sometimes, because I am autistic.
Unfortunately I'm not aware of research to back up these observations; most of it comes from interacting with the autistic community and reading a boatload of essay anthologies and memoirs of autistic people.
Certain gendered language could also be rephrased to be more inclusive. E.g. "people who get heavy menstrual periods" instead of "women who get heavy periods."
Thanx for this remark. Before I knew I was on the autistic spectrum things were much harder for me, too. Depression is such a universal reaction that dealing with it needs a lot of investigation. Most of the work one has to do alone. This is where things may get spiritual. "You have to walk that lonesome valley..."
I agree, even just a note saying 'if you might be on the Autism spectrum, or might have ADD/ADHD, etc, there are other considerations that need to be taken into account; these general suggestions may not apply as well.
And a mention of chronic pain? Apparently about 70% of people w/on-going pain are depressed :-( and treatment has to take that into account and be done differently.
First several grammatical things, like in this paragraph:
“On the neurological level, one line of research suggests depression involves neurons forming fewer synapses, especially in the hippocampus region of the brain. *Remember*, neurons are the type of brain cells which carry thoughts and information;”
I don’t think ‘Remember’ is necessary, you introduce neurons in the previous sentence after all. Broadly it might make sense to move most of this section to a special technical area, and just leave more vague gestures towards the neurologic, biochemical and so on. I like it but worry it might be intimidating. For formatting I like the way some sites will have embedded footnotes w/in the text but don’t know if you want to get into that.
“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 is difficult to visualize, I would add the 3D graph of local minima you’ve used before, maybe with an arrow to the negative point and a label “YOU ARE HERE”
“ (ie develop a negative prior on baseball skill).” Should be ‘i.e., develop a negative etc’
“ But another part of it is that knowing things isn’t enough. I know that if *I lifted weights* every day I could become very strong, I even know some more complicated body-building advice, but the advice itself is nothing” This sounds weird, suggest ‘if I were to lift weights’ or just ‘if I lift weights’.
“Either one when used for too long increases your risk of metabolic problems (eg diabetes) and various terrible movement disorders (eg you can’t stop smacking your lips, and this problem never goes away).” Twice in this one sentence it should be ‘e.g.,’ which means you overlooked four dots and two commas, that’s a lot of missing punctuation sir.
“ For one thing, you’re unconscious and don’t feel it. For another, you’re on what’s called a “neuromuscular blocking agent” which means you’re not really going to convulse (ie won’t flail your arms and legs around).” Here’s another should be ‘i.e.,’
“If your depression returns quickly again in a way that seems correlated with stopping the medication, stay on the medication indefinitely or until something important changes (eg you quit a terrible job that was making you depressed).” Probably should just find / replace the eg to e.g., at this point but I’m committed now.
Overall I think this is a really good and important article and I’m glad I read it and can hopefully make it slightly better. One other suggestion for an option if ECT hasn’t worked: neurosurgically implanted deep brain stimulators, if you’re not a coward that is. https://www.sciencedirect.com/science/article/pii/S089662730500156X
I disagree on "If I lifted weights". I think it's fine, and "If I lift weights" would sound like a non-native speaker had written it.
(As for the i.e. and e.g., Scott has consistently written them without dots for at least a decade, so I assume it's a deliberate stylistic choice)
I think "If I lift weights" and "If I lifted weights" are both good English, with slightly different meanings. "If I lift weights" suggests more intention to me than "If I lifted weights".
"If I lifted weights" is grammatically counterfactual, like "If I had more time" or "If I were President". Using "If I lift weights" to express this counterfactual meaning would be incorrect and sound non-native.
You're right, there is a slightly different meaning where "If I lift weights" would be correct; like "I might, in future, lift weights, or I might not. If I do..."
But I think the "...I could become very strong" fits better with the counterfactual meaning.
Can you write one of these about anxiety? Also, I am wondering why you don't mention the older SSRIs.
I think you are being a coward for putting ketamine so low, and it is not difficult to get. 63 year old psychiatrist here, longtime private practice. I am a very skeptical, rational empiricist kind of guy, but I must say I think the word "miraculous" applies to many of my depressed patients responses to ketamine. Initially I was sending them for expensive IV infusions or IM injections, but I have been using nasal spray racemic ketamine made at compounding pharmacies for about a year now-- it's inexpensive, and dosed properly has minimal side-effects, principally dizziness or imbalance for a brief period after a dose, which diminishes over time. At 100 mg/ml, and with each spray .1 ml, most of my patients end up somewhere in the one-spray-each-nostril, one to three times a day range. I've had some non-responders of course, but lots of patients say no previous med has worked as well.
What makes it hard to find, I think, is psychiatrists who are not comfortable using/prescribing it. This is a barrier to a LOT of 'newer' treatments, especially those that go against previous medical wisdom, like naltrexone for alcohol abuse and low-dose naltrexone for chronic pain.
The discussion of treatments generally includes evidence from trials, but the section on ECT has only anecdotal evidence. An article on Aeon by John Read, a professor of clinical psychology, claims that trials of ECT show very limited evidence of benefits and that there can be serious and permanent side-effects.: https://aeon.co/essays/why-is-electroshock-therapy-still-a-mainstay-of-psychiatry
Is he right, or is there evidence of clear benefits from trials of ECT?
I was writing the following post then came across your comment. Given their similarity I thought I would post it here, in the hope SA responds to the points raised in the AEON article.
This article, https://aeon.co/essays/why-is-electroshock-therapy-still-a-mainstay-of-psychiatry, is scathing of ECT. The commentary is your draft depression page on ECT appears very favourable.
Perhaps the most relevant claim in the article is 'the ECT research literature as a whole has, from the outset, been of remarkably poor quality'. Is the commentary in the article accurate?
I dont have much to add, but just reading this helps me think about it in new ways. It feels like treatment. This feels cheesy, but thank you.
I will say that sad music usually feels very validating to me, at times when no one else acknowledges that i have a reason to be sad.
I am also afraid of ECT because ive heard stories about what it was like in the 50s, and am skeptical that it has really changed that much.
There's some research that shows that people who feel low often actually feel better when they listen to the sad music; validation and not feeling alone! But perhaps there's a time and place for that, not always the sad stuff.
Recognize the fear of ECT for what it is; recognition of a 'rather nasty but effective' treatment (much like chemotherapy for cancer), but also a component of out-of-proportion anxiety based in the popular image. The skepticism is interesting; do you actually not believe when people tell you there have been changes to how ECT is administered?
And when need be, we can do things we are afraid of.
"Doctor, my friend is depressed. What do you recommend?"
Cliche aside, this is actually true. This article is patient is oriented at what a patient or treatment can do, not what to do if someone you care about may be depressed.
I am not depressed but people I care about are. Is there anything I can, or should or shouldn't do? For example I keep inviting a depressed friend to social gatherings with a friend group (while those were still a thing prior to covid). He very often cancels at the last moment, and I tell him it's not a problem. I'm pretty sure he does enjoy it a lot when he does make it. But he knows he's getting a reputation, and is always profusely apologizing afterwards. Is this a beneficial thing to do on my part? I've asked and he says he appreciates that I keep doing that, so I suppose in our case it's fine, but I don't really know any general recommendations.
So perhaps it's worth adding a paragraph titled "My friend is depressed".
I don't know if that should necessarily be a part of this article rather than separate, but I agree that it would be extremely helpful. Some parts of this translate obviously into advice for friends/family members but I'd be very interested into what Scott's take as a psychiatrist is on how much you should prompt people to do things, in what circumstances you should recommend they get medical attention and so on.
"I don't know if that should necessarily be a part of this article rather than separate [...]"
Fair point
Maybe I'm just unaware of the level of acceptance predictive processing has, but to me, the part on priors, etc., seemed more speculative than a lot of the rest of the post. (I know you like this stuff, but is it really known?)
I'm interested in the answer to this: I don't have any psychology/psychiatry background, but from the stuff that comes into my radar I feel like there's SSC/ACX stuff where it's taken as established, true, and explanatorily powerful, and then everywhere else where it doesn't get a mention (at least in terms that I'd recognise). But I don't go out looking for this literature, so I have no idea how representative that impression is.
I know someone who thought he might have depression when his actual problem was an undiagnosed auto-immune disease, due to which he was in pain. (The doctor said: "We prescribe an anti-depressant. If it works, we say it's atypical depression.") As soon as the auto-immune disease was properly controlled, he no longer felt depressed.
Maybe it's worth mentioning that what some depressed people with non-psychiatric issues need is treatment for their non-psychiatric problem.
That's briefly covered in the bit about anemia and thyroid deficiency. But maybe it could be made more general.
YES, I think there needs to be a big bold mention that potential physical health issues need to be WELL investigated first. I saw an amazing Grand Rounds presentation years ago by a very senior psychiatrist, top guy in his field, about a 62 year old male, depression plus some cognitive decline, possibly starting dementia etc etc. The psychiatrist treated him for almost 2 years for depression etc etc. Then finally got thyroid tested and guess what? Presenter went on about what an idiot he felt like, and then revealed HE was the patient!
I also started treating a guy for severe anxiety, classic CBT, and it was two months before I remembered to query caffeine use. Sigh. Once we figured that out, we planned a gradual reduction and I told him to come back and see me if the anxiety didn't get better, or if it turned out he was self-medicating for attention problems. Never heard from him again ...
Hi! I'm a 19-year-old college student, and a lot of your regular readers seem more eloquent than I usually am. So excuse me if these comments are all over the place.
As someone who’s already a fan of your work and writing style and has suffered from major depression in the past (with occasional short relapses every few years), I liked this a lot. I can think of a lot of nerdy friends of mine who might find this helpful as a calm, empowering “go-to” about depression. (Sorry if the whole “nerds will really like your writing” comment is getting old. I would recommend this as a comprehensive guide to anyone because I can’t think of much else like it, but it does seem *mildly* inaccessible to people who are looking for immediate things to do rather than general information backed by studies.) In particular a lot of the comments are asking you add more detailed potential treatments - they might work if it’s been shown to help a majority of people, but I think the “cliche” treatments (life circumstances, therapy, medication, hotlines, diet and exercise) are still the most effective places to start 99% of the time.
I also loved the mentions of comorbidity with physical diseases and with other potential disorders. I thought that was handled really well, particularly in terms of what to look for in treatment.
I like that many of the suggestions are relatively achievable by oneself and don’t necessarily require professional help (though come to think of it, it might actually be useful to state the benefits of professional psychotherapy and medication a bit more, because I know very few people who have managed to single-handedly dig their way out of depression without any outside assistance, except for those where it was mostly based on one terrible life circumstance or something.)
One thought I had is that this might be less useful for people looking to support loved ones with depression - I can easily imagine an overenthusiastic family member reading this and bursting in with a bunch of ideas for potential treatment, which might not be the best place to start. The FAQ seems like a good length and well thought-out in terms of structure already, so maybe there could be a separate document for "supporting people with depression"?
Shorter notes:
-You recommend supplements for everything but creatine - could you add a reasonable creatine supplement?
-Seconding the person who wants treatment plan 3a/3b to be labeled as time/energy and doctor/no doctor.
-I feel like calling yourself a coward over ketamine is… I appreciate the straightforwardness, but I’m not sure it strikes the right tone.
-Why did the light therapy come after magnetic and ECT? I feel like since you mentioned light boxes before… I get that it makes the tone a little calmer though.
-Talking about anxiety and depression as having huge overlap then “make sure your depression isn’t caused by anxiety” in 2.6 is somewhat confusing.
-The instances in which you suggest something might work better but can’t in good conscience recommend it because of lack of evidence might give off mixed messages - desperate people might interpret it as “he’s secretly recommending the one with less evidence but is trying to be sneaky about it.”
In part 1, I found the paragraph on the attractor state sticking out negatively. You explain most other difficult concepts in simple terms, but you expect your readers to know what you mean by an "attractor state in a dynamic system". Also, while I understand what you mean, I found this fourth description to be less helpful than the other three.
There are some abbreviation that you assume your readers to know. I guess they know OCD, but do they know PTSD and DSM? (Little confidence, non-native speaker here.)
Seconding the bit about dynamical attractors. Maybe use another metaphor (balancing a coin on its side?).
"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."
I think the HAM-D is a rating done by a psychiatrist (after some clinical interview), it's not a test that one can self-administer. So maybe consider rephrasing "take the HAM-D".
And maybe remove the word "exactly" :-) Such tests generally have low reliability (0.75, say). Let's say a glazier uses an instrument with that precision: it's like you order a window that is 1m x 2m, and then the glazier brings one with, say 80 cm x 170 cm or so...
Really interesting, but not a word about psychoanalysis in the types of therapies?
I mean, can you really recommend it in a good faith?
If all therapies have roughly the same effectiveness on average, but one requires way more sessions for the effect - does not it mean that this specfic therapy is the least preferable of all. And that appears to be the case with psychoanalysis - it's more expensive in every aspect really. Longer session, more often, for longer periods of time.
I can see one case for it - if you have tried everything else and nothing helped, and that's your last hope. But other than that, why would you want to recommend it?
I think it works for some people better than for others. The issue with pricing is troublesome indeed, but I think Freud argued that there was something symbolic about sessions being costly, something like paying a price and leaving a part of you in there. It's hard because it has to be hard. I think it depends on the kind of therapist you go to (Freudian, Adlerian, follower of Winnicott or else), but sessions need not be long or short. Sometimes it takes longer, sometimes it takes only 15 minutes (and the price may vary as well, though today I think therapists tend to stop doing that). There is also a whole process of sitting in the chair then lying on the couch and transference that makes sessions inhomogeneous.
I'd recommend it if you want to know *why* you came to dysfunction at that moment of your life. Sure, antidepressants are great, but they don't do that. They don't give meaning to the particular kind of hell you go through.
Psychoanalysis has been shown to be an effective treatment for depression, as has it's less-expensive-and-time-consuming cousin, psychodynamic psychotherapy. And for all sorts of other things, including Borderline Personality Disorder. (Just not for anxiety, PLEASE PLEASE PLEASE! If you want to know all the deep reasons for your anxiety, go to psychoanalysis AFTER you do the CBT that will actually help.)
Yes, time consuming and expensive. But the changes are DEEP and durable. And if you can afford the time and money, a super interesting and often fun (and often very painful) experience.
Really enjoyed this; two thoughts I don't believe I've seen others bring up:
- The mentions of light therapy seemed a little scattered across the piece; it was a little jarring coming straight after the ECT section, and its inclusion there seemed more about providing humorous relief (a la 'arson, murder, and jaywalking' https://tvtropes.org/pmwiki/pmwiki.php/Main/ArsonMurderAndJaywalking) rather than because it fit well in that section.
- As others have mentioned the 'mathematical attractor' analogy is perhaps offputtingly-technical; an alternative analogy that captures the same broad sense could be an analogy of a surface with differently-sized holes (this is a gravity well analogy without introducing physics terminology), where some people's neurology/psychology/whatever is set up so that certain circumstances put their ball (current mental health state) near the 'depression' hole, and then it gets pulled further in; depression is one stable position of many/several. Interventions aim to bounce the ball outwards in the hope that it can find a different stable position.
I hope you write the same guide for OCD
(1) Everything following comes from an Irish context, therefore not universally applicable.
(2) I don't know if I have depression. I feel depressed, but at my initial (and only) assessment appointment for counselling, the counsellor said, quote, "That sounds like mood swings not depression" so I have no Official Diagnosis (my GP wouldn't even give me anti-depressants, again, quote, "We don't do prescriptions anymore" so I got shunted off to the "but now we do counselling!" route).
(3) Is there a difference between counselling and therapy? I feel like there is, but I don't know enough to say. Anyway, it was only counselling and not therapy on offer, if that makes a difference.
(4) I HATE, HATE, HATE, that in order to get help, you have to stick to acting out a script. I was ignorant of this, answered questions honestly, and as a result ended up with nothing. My own fault, I should have researched before I went in. Plus, ironically, having worked on the 'other side of the desk', I absolutely understand the requirement that "you have to sign this contract stating that you will indeed turn up for all the ten sessions of counselling", otherwise you don't get anything. I have been that public/civil service minion. I know what such schemes entail and why they have such conditions attached.
As a potential - patient? client? what is the proper term? - it felt very odd that executive dysfunction, which is a known symptom of depression, wasn't taken into account. On the very bad days, I can't even commit to getting out of bed. I can't commit to cooking a meal, even when there is food in the house and I am hungry and it will take 15 minutes tops. And you want me to sign a contract saying "yes indeedy-doo, I will definitely turn up every week on the hour bright-eyed and bushy-tailed for our session!", well like a fool, I said "I can't commit to that", so no counselling. (And I *understand* why! But it's still making me grit my teeth and scowl when the well-intentioned ads come on the radio about "help is out there!")
Help is out there *if you know the script and stick to it*.
(a) You cannot know anything about the problem. No, not even if it's something you're long-term living with. Doctors do not like it when you use medical terms; they feel like you're telling them how to do their jobs and that you're a hypochondriac who just looked up vague symptoms on the Internet and now think you have cancer. Dumb yourself down, you have to be the humble supplicant who is "oh doctor please help me, you are so wise and competent".
(b) Agree with everything (to an extent). Again, like a fool, I said "no" when asked if I was self-harming or had attempted suicide. Apparently just *thinking* about killing yourself doesn't count; unless you're self-harming or have attempted suicide, you are Not Really Depressed (Enough).
The trick here is to agree *just* enough to fit with the script, but not enough to trigger "well, better sign you into the ward for involuntary commitment". This is where the 'cry for help' attempt works best (e.g. take an overdose of something that won't actually kill you, call the ambulance, go to hospital to have stomach pumped/be kept in overnight for observation; get to see psychiatrist. Profit!). Unfortunately that won't work for me, as if I do ever get the courage to try suicide, I am not going to fuck around with 'cry for help'. I have a method that I know will work.
Anyway, next step!
(3) Agree with everything, part two. As I said above, even if you can't commit to washing your face tomorrow much less turning up every week, don't say that. Nod and smile and sign on the dotted line. Next week is a whole week away and who knows, you might even be able to turn up to the appointment on time, miracles do happen.
(4) Don't be honest. Even if when the counsellor trots out the watered-down quickie version of CBT which boils down to "think happy thoughts!", don't say anything except something along the lines of 'oh wow, I never thought of trying that". If you're like me and naturally sarcastic, bite your tongue. Sure, "think happy thoughts" won't work if your situation really *is* objectively shit, but you're not going to get anything better. It is now Gospel that CBT cures all, and if it doesn't work for you, the problem is you: you are Not Doing It Right. This is as good as you're going to get, so take it. Maybe it will help a bit.
(5) The main thing is, this is the script you have to act out to show that you are a Good and Deserving and Compliant Patient/Client. Otherwise, you get nothing plus you are tagged as a Bad and Non-Compliant Troublemaker.
I wish I had known all this *before* I went and failed to get the help that I am constantly assured is on offer, but there you go. Learn by my mistakes.
Yeah, it's only "learning by experience" that teaches these things, unfortunately, which means that it's too late when you do find out that you should have played the "I know nothing, I am from Barcelona" script. https://www.youtube.com/watch?v=nX7CeTXoxyU
"With lifestyle changes, you could potentially treat them the same way as medication, but also, consider sticking to a healthy lifestyle permanently."
Okay, enough of the pointless whining and complaining, time to try and be helpful.
Lifestyle changes are *hard* when you're down. Like I said, I can't even make myself cook something to eat when I'm hungry, and now you want me to draw up and stick to a regime of exercise and healthy eating and uplifting activities and - look, can I not just go back to bed and sleep for fourteen hours straight?
The "fresh air and exercise will make you feel better" thing actually had the opposite effect on me; it was when I *was* taking healthy exercise in the fresh air and sunshine that I seriously started contemplating throwing myself off a nearby bridge, the only reason I didn't go through with it was that I couldn't be sure the bridge was high enough to kill me instead of leaving me alive but quadriplegic or similar.
Well-meaning advice is really annoying and unhelpful, but on the other hand, when you're bogged down in the Slough of Despond sometimes you really do need someone to keep nagging you to change and stick to it.
CBT is NOT 'think happy thoughts', and anybody who is presenting that way is a shit therapist. Or maybe a counsellor (usually means less training (ie cheaper for the system) and traditionally counsellors dealt with 'general life issues' and not actual mental illness).
I possibly am being a little unfair there. I think that CBT will work really well for some people, maybe even many people, but that there will be people that it won't work for.
As Scott says, much of the advice for treating depression sounds easy but is hard to do. And the assumptions behind CBT (which I may be mistaken in taking as assumptions) seem to be that "things are not as bad as you think" - Scott's example of the person with a good job, a nice house, a loving family, etc. who thinks they've done nothing with their life. So the technique of realising and cutting off negative thoughts and instead reminding yourself of the positive reality works there.
Where your objective reality is not positive, then it does sound like "think happy thoughts!".
I honestly don't know how much room there is in CBT for "things are bad, but not *that* bad".
For me, the most useful way of conceptualizing depression is to think of it as a self-sustaining cycle: depressive thoughts lead to negative emotionality, constantly feeling bad leads to bodily dysregulation, and bodily dysregulation and negative emotionality *produce* depressive thoughts.
When I was suicidally depressed, that last part was very hard to even imagine, because I used to feel like I "was" my thoughts. As in, whatever I considered to be my self, my consciousness, my will, whatever you want to call it - that it was entirely isolated and embodied in my inner voice. I was the one doing the thinking. Whenever a negative thought popped into my head, it had to have been "me" who thought it, and therefore "I" was now thinking about that depressing thing and ruminating on it and pursuing its every implication for hours and hours, over and over again in order to get to some kind of resolution, some lesson to be learned, some revelation that would improve things if I just thought about it hard enough.
I was those thoughts. It never felt like thoughts could be introduced into my consciousness against my own "will". I thought, therefore I was (depressed).
And when anti-depressants seemingly failed to do anything at all for me, I took that as further evidence that I wasn't really ill ; I had by then reasoned that my depression wasn't anything abnormal, but that it was a rational, reasonable reaction to both my own failures and the general state of *gestures vaguely at everything*. How could I not be depressed? It would have been abnormal *not* to be depressed. Not being depressed was suspect. If I were to stop being depressed, it had to be because my reasoning became faulty. I had to have somehow become a less rational person ; which is, of course, absolutely unacceptable. Therefore, my fate is to be depressed and miserable, for the entire rest of my life. And since this is also terrifying, I have no other option but to (rationally, reasonably) kill myself.
I suspect this is a trap that a lot of hyper-rationalizing introverts with a huge ego tend to fall into.
What ended up helping me in the end was not to find a better way to think about my problems, but to not entertain depressive thoughts at all. To stop trying to figure out a rational solution, and instead force myself to notice when I was thinking depressive things and then simply decide to think about something else. Doing that is, as it turns out, way harder than it sounds - things like mindfulness meditation do help you figure out which mental muscle you need to pull to make that happen - but for me, after years and years of following the same depressive thoughts to the same depressing conclusions over and over again, I had gotten so used to all of it that I barely even bothered thinking it through anymore. I just caught myself and went "yeah, I know how that goes" and simply gave up.
As it turns out, that's basically all it took. I had some fears that I was repressing my thoughts, whatever that means, and that it would somehow end up making everything ten times worse - but over the course of ~1-1.5 years, I spent less and less time thinking depressing things, and while nothing else changed in my life, I found myself physically less and less depressed, up to the point where I could just say "I'm happy" and "I want to live" out loud, and it didn't sound completely and utterly alien.
I still have leftovers from that broken mode of thinking - for example, my instinctive reading of 2.1, when you write "the most powerful treatment for depression is GETTING AWAY FROM THE DEPRESSIVE THING", is that it says I should kill myself (since I am the depressive thing, and there's nowhere for me to get away from myself). Even though I know of course that you never intended it to be read like that, I know past me would have read it like that and believed it.
It would have tremendously helped me back then if someone had suggested just trying to treat some of my thoughts as potentially adversarial and unwelcome - and given me the assurance that doing that wouldn't really turn me into a different person. I am still very much the same I was back then in many respects, my life situation isn't that different, and the world is still generally as disappointing and as exciting as it used to be. The difference is, I'm no longer depressed and no longer suicidal, I am much happier for it, and I could have been like that 8 years earlier if I had had those mental tools back then.
All that being said, it is only what worked for me. I have no idea how strongly it reflects the actual reality of depression for everyone else. I do think the model of the self-sustaining psychological/biological cycle is an extremely useful mental health tool, because once you see it that way, you can start tugging at multiple sides of the issue at once instead of treating them separately. It also goes a long way in explaining the wild differences in treatment effectiveness between individuals:
1) People who don't usually spend their time ruminating and rationalizing can still end up falling into the attractor state and be kept there from purely biochemical factors - but any effective antidepressant should also pull them right out ;
2) conversely, people who don't really have anything badly wrong with their neurochemistry outside of what's directly caused by the whole "ruminating depressive things 24/7" will probably find antidepressants ineffective, and CBT super effective.
3) In most cases, no matter which cause is predominant at the start, you still end up getting both the physical dysregulation and the negative thoughts. Once the cycle is started, either of them can and will keep fueling the depression engine - so this also accounts for why psychotherapy and medication work better together than alone.
"a trap that a lot of hyper-rationalizing introverts with a huge ego tend to fall into"
It me. Most of the elements that helped me to recover from my terrible depressive spells in my 20s were external factors - moving to a town I like, finding work that I like and which pays enough for me to live, meeting & marrying my wife. Talking therapy has also been very useful, if only to set aside an hour every two weeks to put aside everyday concerns and take stock. However, in terms of the stories I tell myself, one useful technique has been to try to unbundle the self, for lack of a better term, through meditation & art.
Reconceptualizing the self not as a single monolith but as a confederation of different voices seems more congruent with my experiences in meditation. That realization that there's different inner monologues which are always running, not subject to conscious control and which are best regarded with a spirit of curiosity and lack of judgment was important. Some of these voices are internal representations of people who have been important to me and who seemed to find me wanting. This shift in how I conceived of my self felt as if it made the space for me to change myself, to realize that it wasn't actually these people and their opinions of me which was doing something to me from the outside but that one part of me representing those people was keeping the other parts of the self pinned down.
One artistic representation which I encountered recently and found very moving and useful as a mental shorthand is the passage in Hesse's _Steppenwolf_ where Harry goes into the room in the Magic Theater marked "GUIDANCE IN THE BUILDING UP OF THE PERSONALITY. SUCCESS GUARANTEED." Hesse came along at a good time for me. In some ways, I wish I had read him before, say, the French existentialists, but then again I might not have been ready to hear what he was saying.
Your reply here and Vim's above are so well said.
It's a basic tenet of CBT (and a bunch of other therapies) to learn to disinvest quite so much reality in one's thoughts. To practice seeing thoughts as thoughts, not as reality. It can be really hard to help a person start down that road because investing a lot of reality in their thoughts is a deep habit and defense for a lot of smart people.
In then in a not-so-dissimilar way, Buddhist psychology and all the mindfulness practices are also designed to insert a gap between "this thought I'm having" and "what reality is." Their teachings about not investing too much reality in the "self" and all its shenanigans is central to that.
Yup, and CBT's new cousin, ACT, has an even greater focus on recognizing, accepting, then moving away from the 'not useful' thoughts and feelings.
I've found 'not useful' to be easier for people to accept than 'not reality'. That covers the thoughts/feelings that are disproportional, the ones that are distorted, the ones that are correct but perhaps we don't need to spend ALL our time focussing on them, the ones that we've thought/felt plenty about already and now perhaps we can move on .....
"Not useful" is a nice formulation. Buddhists tend to say "unskillful" and that seems judge-y for people who aren't on that road. The next layer down is that those thoughts and feelings are useful to some part of the person and that's what makes them so sticky. But there's not always room to go there with someone.
And that's a lovely way to describe that there are lots of different categories of thoughts that don't serve us well, from the more distorted to simply the ones it may not help us to marinate a lot in.
Maybe explain more about what an attractor state in a mathematical model is. Seems like fairly impenetrable jargon
Great writeup overall. Some comments:
1. You avoid mentioning the term "dysthymia" (low-grade chronic depression) at all. I feel this is a very different beast than, say, a six-month major depressive episode, and lumping both under the label "depression" may be confusing. Dysthymia is both more subtle and probably more difficult to treat (in many cases, at least).
2. You mention "trauma" only in passing. I'm very interested in various trauma-oriented types of therapy (esp. somatic - Peter Levine's Somatic Experiencing, Bessel van der Kolk etc.) and IMHO this topic warrants more attention and space. It may be even more important than discussing meds. I suspect that _most_ cases of depression, esp. chronic (see item 1 above) are in this way or another related to past trauma, especially early trauma. When you write: "f you suspect that your depression is related to stress over a trauma you’re having trouble processing, I would recommend worrying about the depression only long enough to make sure you’re stable, and otherwise putting your effort into pursuing therapy for trauma.", it sounds like you're treating these two conditions as somewhat separate and independent, which I strongly believe not to be the case in a lot of situations.
3. Related to item 2, I emphatically DO NOT share the general enthusiasm about CBT-based therapies. I don't want to discard the evidence of scores of people who where helped by it. But for a certain type of people (myself included), CBT is one of the worst types of therapy available and can even be harmful. How so? In many people, a defense reaction against trauma (again, strongly correlated with depression, see 2) is some kind of dissociation, and in intellectual minded people this dissociation often takes the form of "locking oneself inside the head" (i.e. cutting oneself off from bodily sensations, emotions etc.). Mental/cognitive interventions only reinforce this pattern and keep the patient locked in their mind, despite treating emotional depression-related content on the object level (but, crucially, not on the process level!).
Much, much more can be said here, but I'll just try to highlight main points around this:
* Depression is often a surface symptom of sth else (e.g. past trauma) that requires deep transformational work to heal.
* It's impossible to do deep transformational work purely by intellectual/mechanistic means.
* As a culture, we like intellectual/mechanistic methods because: a) they have the semblance of being "scientific", so "predictable"; b) they allow us to disregard the body experience as something secondary (this is a very strong and old streak in Western culture in general, starting perhaps from Plato)
Therefore, we like CBT and tend to treat "less scientific" modalities with skepticism ("How do I know this is not some New Age bullshit? How do I know this is not placebo or anecdotal evidence?"). I don't necessarily advise doing "spiritual enrgetic DNA healing" as an antidote, and definitely there is a Pandora box of therapies that range from "not proven, but probably make sense" to "totally bogus". But consider the possibility that the scientific understanding of the body-mind relationship lags severely behind the empirical knowledge of practicioners. So "what can be proved in RCTs as of AD 2021" might not be the best indicator of what actually works, and it will take maybe 30 more years for science to catch up.
What is your proposed mechanism for how trauma contributes to depression? IMO there are many different possible pathways. The main three I can think of:
- (fragility threat) trauma => constant low-level stress => increased external stress tips over edge => depression
- (epistemic threat) trauma => globally less positive priors => get sucked into bad attractor => depression
- (arousal threat) trauma => worse sleep => depression
Presumably, in each pathway there are ways to ameliorate the depression by addressing the intermediates, rather than the underlying trauma. This is attractive because identifying the trauma at play is non-trivially difficult, and reconsolidating can be a disruptive process. When I did EMDR for cPTSD, it cut my productivity on treatment days by at least 50% — between that and the fact that trauma treatment is not really something one should do with a book and therefore requires locating a therapist and getting the requisite time and funds in order — it's not something everyone can make happen immediately. Obviously people with trauma should address it *soon*, but there are presumably many situations where someone is not going to begin treatment for another month or so but needs relief from depressive symptoms *now*. For these people, I imagine something like CBT can be a good way to prevent them from slipping further into the attractor sink in the short run, even if it won't make a huge impact long term.
I also am not sure I understand how CBT would make a person with trauma more dissociated with their body. In my case, before therapy I was basically totally detached from my body — I'd constantly get really bad injuries while running competitively because I wouldn't feel them until they became debilitating. Imo, I'm not sure there's anything that could have made me much more "in my head," let alone something like CBT which is mostly about challenging arising thoughts rather than adding to them.
Also, a word in favor of CBT — despite having trauma with a pretty serious bodily impact and being naturally pessimist (basically the two biggest risk factors), I only ever had one brief depressive episode, and it came from literally sharing a living space with people of the gender associated with the trauma. I just did the exercise/diet thing and it went away in a month or so. My sense is that this is probably due to the fact that I lack an inner monologue, and so don't deal with the whole rumination thing. Apparently this is a common observation and those lacking an inner monologue really are insulated from depression/anxiety. I interpret this as evidence that internal monologue has a very strong contribution and something like CBT really could make a big difference. This (monologue contribution) may be related to why depression is a Western illness, but that's speculation.
If I had to guess, this is why meditation is effective. It seems like most meditators are just trying to achieve mental chatter with low emotional salience, if not complete extinction thereof. My worry with meditation is that it changes the brain (adds to pfc, adds to hippocampus, subtracts from amygdala) in a way that might be helpful for anxious types but not for depressives. Should we really be encouraging depressives to do something that is designed to help people eliminate desires? Hence my preference for CBT, which seems more harmless. Although ofc I can't speak from experience here — I'm not sure how CBT would even work for someone w/o internal monologue. If someone finds out, feel free to inform me though! Maybe something like doing free association writing and then writing out responses?
I'll try to find the link, but I saw an article a couple of years ago that showed that meditation and especially the exercise/meditation combo improves learning (in the broad sense as well as the specific). So I'm betting we're going to find that those synapses and new/more connections are involved.
If that's the case, it could be useful in depression too, as long as the other work on reducing those negative priors etc is also being done.
HOWEVER, I have yet to see research that shows meditation actually WORKS to improve depression, per se. I've actually seen some (a few years ago now, though, so there may have been updates) good evidence that it does NOT, at least in reducing recurrence/severity/length of depression in people for whom it tends to recur. But I'm not up to date on this stuff, must go do a search now .....
And there are definitely other ways to deal with rumination besides meditation.
You might be interested in these;
https://getpocket.com/explore/item/psychologists-express-growing-concern-with-mindfulness-meditation
https://getpocket.com/explore/item/psychologists-express-growing-concern-with-mindfulness-meditation
Did you mean to link two separate articles?
Is the idea that meditation and exercise both improve the hippocampus, and that's how learning is promoted?
Thanks for mentioning dysthymia, I didn't know the term and I think it's a way better way to describe what I'm living. Do you know if the treatment for it differs from what is recommended here? I feel like at least most advice about lifestyle change would apply, but I don't have any evidence for it other than """common sense""".
Anti-depressant medications can make a huge difference for some people with dysthymia. Of course, like everything depression-related, it doesn't help everyone, nothing does.
For patients with dysthymia, I've had good luck using behavioural activation. Have to start small and help the patient be fairly consistent. Logging activities and mood/energy is VERY helpful for that, as the changes are subtle but add up, and of course, the dysthymia itself leads the person to focus more on the 'not-working-ness'.
The behavioural changes that are most often helpful that I've seen have been; more frequent low-key social contacts, more frequent exercise, preferably with other people and/or outdoors, and making their living space more pleasant/serene. That last one often takes a big effort with assistance; getting family or friends or a cleaning company or community services involved to do a BIG clean-up, sort-and-discard and re-organize. After that our goal becomes the small tasks the person can do on their own that keep the space nicer. I include some self-care in that 'more pleasant livings spaces' such as regular haircuts and shaving, having something nice-looking to wear daily. Not talking fancy clothes and certainly not uncomfortable; in good repair, fit ok, clean, colours the person likes ... I tell them this is part of their living environment, as they have to see themselves all the time!
I encourage people with dysthymia to see these efforts as an experiment; if they do all this stuff and feel/live no differently, they can stop! We figure out a reasonable time-frame for the experiment, and use the logging to see whether the changes are sustainable and whether helpful.
And most importantly, I tell them 'most people can determine whether they want to do whatever it is (socialize, tidy up, go to the gym ...) and then decide whether to do it or not. You, however, cannot! You need to figure out what helps, then DO IT, whether you feel like it or not, whether you think (in the moment) it will help or not, and whether it is immediately helpful or not!' I often compare it to having diabetes or any other chronic health condition; you have to do more to end up 'the same as most people'. We even make a list of 'actual reasons NOT to do the things you've determined are helpful', so they don't default back to not doing things (basically; would your doctor recommend you not go out to game night at the pub or not go to the gym today?'. If it's not on the list, they know they should do it. Having some kind of buddy system also helps; knowing you're going to game night and XYZ person is expecting you/will come by to pick you up if it's hard to get going/will text you to encourage you to go is great.
Thanks a lot for taking the time to write this. This sounds really valuable and actionable.
are you currently accepting new patients? sorry if this is an inappropriate question
Not inappropriate! But I'm not; a LOT of people are struggling right now, and I'm pretty swamped.
Thanks for the vote of confidence, though ....
Look for a very good CBT/ACT therapist; they should be able to do this stuff.
The thyroid thing was key for me. Most of my adolescence and early adulthood I had periodic waves of anxiety and depression. I’ve had nothing like them since I started treating my thyroid. My advice on this would be to include that many common thyroid conditions are *cyclical*, so a single thyroid panel may not catch it. I had one high result on routine blood work, which is why my doctor suggested we keep an eye on it, but it took repeated tests over nearly two years to see a pattern for me.
I had no pronounced symptoms, nothing “bad enough” that I even considered seeing a doctor. So we caught it early. In retrospect things like my mild-to-moderate anxiety and depression, concentration issues and high cholesterol were probably connected to my thyroid problem, since all of those things basically disappeared once I started treating it. Not to mention that I hopefully avoided the further trashing of my endocrine system, the results of which can be damn depressing all on their own.
The medication I take has been around for decades and is very cheap- if some people can manage their depression by managing their thyroid, that’s a got to be one of the easiest and most affordable outcomes, so if more people got diagnosed early it would be a giant win. But you can’t rule it out after only one test!
I remember one of the first things my psychiatrist recommended when I was first diagnosed with a mood disorder was to check the thyroid levels (the next thing was having me go through a sleep study), unfortunately that wasn't the issue for me (I think I was checked multiple times on this although this was roughly two decades ago so my memories are fuzzy), but nice to see it was a competent instinct.
I am compelled to comment on the connection some appear to be making between "dysthymia" and thyroid. My day job is that of a PCP, and I think that 50% of what I address most days is mental health. The root word "dysthymia" comes from the Greek "thymus" which is a term that generally means vapor or spirit or mind or emotion. Greek medical terminology referred to the gland within the mediastinum (essentially the space/potential space between the heart and the sternum) as the thymus. This gland produces T-lymphotes until early adolescence and then completely involutes, so much so that it cannot be found any longer in most adults. It is then reasoned that the Greeks named this particular gland, thymus, because it becomes nothing but a vapor. While everyone struggling with mood disorders, and many other things, should have their thyroid function checked, "dysthymia" and thyroid are similar terms. Perhaps this is the answer to the question posed by MK above about not mentioning "dysthymia"... people easily confuse it as being a thyroid issue when it is not.
Plus someone with thyroid issues can look a lot like they have dysthymia and vice-versa. So it's always an important differential diagnosis.
As I understand it, thyroid is hard to diagnose-- presence of the hormone in the blood is easier to check than the body's ability to use it.
Re: 4.: My depression (or at least depression/anxiety-adjacent experience, having never been formally diagnosed) manifests itself as feeling bad -> procrastinating -> not honouring commitments and/or increasing stress due to approaching deadlines -> self loathing -> feeling bad -> … The single biggest thing that helped me was using Beeminder, which I am fairly certain I discovered as a result of your 2015 post about willpower.
It is far from a magic cure-all, but it was so instrumental in helping me finally end a self-destructive cycle of failure and shame (and thereby helped me be ready to see and seize other opportunities to improve my life) that I am not being hyperbolic when I say that I believe it saved my life.
My first two goals were to do one pomodoro a day of productive work, and to whittle down the size of my inbox by ten messages. I'm a little more ambitious now, obviously, but that was all it took to get started on turning my life around.
I would have loved a citation or a link at the "drilling a hole into rat skulls and injecting BDNF cures their depression" mention, as well as one for how antidepressants treat good-reason-depression as well as random.
The non-technical explanation for your second question is that the medication (when it works) gives people a bit more strength to deal with the good reasons for being depressed and to keep functioning while they have good reasons to be depressed. They won't work for long or be all that useful if the 'good reasons for being depressed' aren't also addressed or changed in some way, they're not 'happy pills' that work independently of real life circumstances.
The one thing I would try to mention very early on: "Different remedies work for different people. It's important not to give up because you tried one thing on this list and it didn't work. Any given intervention has a less than even chance of alleviating your depression, but your odds get very good if you try three or four different things."
That could be paired with the *go into as many rooms as possible each day* strategy.
"This will not work for most people, but it was free to try and has worked for about N% of my patients." ?
Why aren't biohackers playing around with TMS devices? I assume the main bottleneck is cost. A quick search suggests a TMS machine is in the $50k-200k range. But why is this? They're "just" a bunch of coils, and they seem easy and safe to operate. My best guess is that the coils need to be tiny and oriented carefully to give good spatial accuracy and precision, but even then $100k sounds like a lot. I'm quite confused.
I've experienced depression once in my life, last year after lockdown+bad breakup. Treated with venlafaxine with no withdrawal symptom (but my doctor made me stop *very* slowly, over 3+ months). All your advice about exercise and getting out of the bad situation matches my experience. What I find incredibly helpful in your post, and would have loved to read back then, is the plurality of causes and the link with anxiety. I couldn't help asking myself: "am I just anxious and sad because of this break up? is that genuine depression? am I a fraud and just making this up to feel better about leaving my partner?" I have no clue whether the scientific part of the article is relevant, but I cannot stress enough how important are the parts removing guilt and second-guessing for the patient.
Misc. feedback:
At one point you refer to ECT out of context. Many readers will not know/remember what you’re referring to from the acronym alone.
At another point you say people should not “try” drugs or therapy if they don’t think they’ll like it. It seems to me you should say they should not -continue- if they aren’t happy with it. (I have a relative who “doesn’t believe in” trying either one, with a predictable (lack of) results.)
I agree with other commenters that some parts are likely too technical or detailed. For instance, maybe the reader doesn’t benefit from knowing your ranked order for prescribing various drugs. As another example, the bit about attractor states doesn’t make sense without more context (context which I’ve read in your blog before), but I don’t think delving into attractor states is super helpful for the reader anyway.
The word “availabilities” is not one I’d ever use. Perhaps it’s common in your field but not in the world at large?
I found it odd that you said people might not want to do therapy because it’s boring or hard to get to...without mentioning perhaps the biggest issue, cost.
Typo: refri(d)gerator
Thanks for sharing!
It would depend on the market you are going after. If you want to appeal to the median ACT reader then this may not be a problem. But I think for most of your potential clients this paragraph doesn't add much value. I'm more of a business/marketing person so that is the basis of my critique:
"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."
"Realistically, most people know if they’re depressed or not and don’t need to go through a checklist to figure it out. "
I'm not sure about that. I think there might be some selection bias going on due to your being a psychiatrist. You only deal with people who are seeking treatment. It's very likely they know they are depressed. That's why they are meeting with you. It's the people who are depressed that you don't see that are going through life thinking how they feel is normal.
Three comments:
1. I'm not sure if it's exactly on point here, but I'd like to thank you for your article about Zembrin about a month ago.
I'd been feeling depressed, but not enough to go see a therapist. Having trouble sleeping, not feeling motivated. I'd been trying to find a new job and was not successful. I guess technically I was/am feeling depressed but figured, 'this is just life and it sucks sometimes, there's nothing special that warrants help.'
After reading your nootropics article on Zembrin, I thought I'd give it a shot. I've noticed I'm sleeping better, dwell less often on negative things, and feel more motivated at work.
Even some OCD-like things I would do have stopped. For example, I often have the feeling when I leave the house that I need to go back and check that I closed the windows or that I locked the door. I would walk all the way down the driveway, get in the car, and then have to go back in to check, even though I knew it was irrational. I still sometimes get the nagging feeling, but I don't feel the compulsion. I'm able to say to myself, 'I know everything is fine' and I leave.
2. I was very interested in and surprised by the parts of this article that talk about the impact of making major changes. I had read (pop-sci type stuff) that people basically have a kind of homeostasis of happiness. Good or bad events can happen, but people usually revert to their individual mean happiness.
This always seemed like an argument against making major changes. Why make a change if you'll still just feel the same afterwards about the new thing. I know a person who is always changing jobs. They start off liking it, discover all the annoying things about it, decide they hate it, leave and then go through that cycle again at the next place.
I wonder if there is a way to discern which people will be helped by major changes and which people have more intrinsic problems.
3. Anecdotally, I have noticed that people do not know what will make them happy and should take a more empirical approach to the subject. I wonder whether there is any scientific basis for this or if it would be helpful for depression. I have made some major life decisions that I was initially reluctant to do on the reasoning of "other people have done this thing and seem very happy with their decision, so I should ignore my reservations and do it".
On the Hamilton Depression Rating Scale, for the Hypochondriasis part of the assessment, they include in the scoring "Querulous attitude".
Ah, so *that's* where I'm going wrong! Thanks, this made me laugh 😀
Re: the bits about "ask your doctor for this medication" - this makes the American medical system sound very interesting to me. I tried asking a doctor (not my current GP) for a repeat prescription of anti-anxiety medication and got shot down with "no, it's habit-forming". The initial prescription had been for ten tablets to be taken as needed over a six-month period. After six months I had used all ten. No dice on any more because that means I'm an addict.
Do American doctors really go along with "of course, I'll write that up for you" if you go in and ask them for a particular medication at a particular strength? Is this because of your health insurance system, where the doctor is an employee (so to speak) and 'the customer is always right'?
There are some significant differences based on your earlier comment about trying to find a therapist and having to say specific things and commit to a specific timeline to see someone. That doesn't so much happen here. But if the anti-anxiety medication you're looking for here in the US is a benzodiazepine, then you're going to get the same response. Benzos, while extremely helpful for many people, have come to be seen like opioids in terms of the reluctance that doctors have in prescribing them. So when doctors talk about "medication to treat anxiety" these days, they often just means SSRIs.
I'm in Canada and here, too, docs REALLY don't like it when you ask for specific meds. I go about it in an indirect, very respectful-of-MD's-professional-knowledge kind of way. 'I've heard that XYZ can be helpful for this, but I don't know enough about it. What do you think?' or 'my friend is taking XYZ for this, but I don't know enough to know whether that might be useful for me, too. What do you think, doc?'.
I straight up just ended up bullying my current GP into giving me one specific medication, when I knew all the good reasons to use it and she didn't have any actual reasons I shouldn't. I looked her straight in the eye and said 'Is there a specific reason you won't prescribe this for me?'. But I know that a) took a lot of balls, which not everyone has or should have to have to get good care!, and b) damaged the professional relationship with my GP long-term, a very not good outcome.
Recently I'm getting SOOOOOO fed up with coaching my patients to ask their docs (GPs or psychiatrists) for naltrexone for alcohol abuse and low-dose naltrexone for chronic pain/fibromyalgia/IBS combos. It's not working! Why won't docs at least go look it up and discuss it intelligently in a next appointment?
I am an "American" doctor, work daily in primary care, and evaluate and treat an extensive wide variety of mood and other mental disorders. Maybe a perspective from the inside of the system might assist in clarifying something for you. Patients do sometimes ask me for specific medications or mention medications they have researched or heard about from family and/or friends, and this does not offend me. My decision to use or not use medication is based on multiple factors including diagnosis, severity, potential therapeutic benefit, medication interactions, potential for adverse effects, comorbidity (other and potentially unrelated conditions), age, pregnancy, lactation, abuse potential, etc. I use benzodiazepines when appropriate and when the therapeutic benefit is high. I also decide against using them. I regularly prescribe most of the medications mentioned in the piece by Scott, and I refer to psychiatrists when the complexity of a particular patient is beyond my level of expertise or level of comfort. My decision to use or not use a particular medication or therapy or make a referral is never based on my employment status. It is based on what in my opinion is best for that individual patient.
Thank you for the article, and thanks for mentioning that feedback about typos is welcome. I haven't found any but I'm never sure if I should mention them if I find any. I like that it's explicit here.
Responding to your #6: I want to offer some general writing advice that I think will make this more accessible to your target audience without sacrificing the great information you've included.
1. As much as possible, limit the amount of new vocabulary a person has to learn just to understand a section. I know the point is to help your reader learn about new concepts, and you mostly do this very well. But in some places you're likely to lose people in ways that are avoidable. The routine use of words like heuristic, global, cluster, cognitions, algorithm, unipolar, allele, eosinophilic, receptors, etc will bog a lot of readers down. Many of these terms can easily be omitted or replaced.
2. Be very careful how you communicate uncertainty. Your blog readers are used to reading "I am very non-confident..." But most people feel insecure when someone in a position of authority talks like that. Alternative phrases include: "It is still unclear why", "The specifics of this topic are still being studied...", "There is some evidence that...", "Research is ongoing", you get the idea.
3. Be very careful how you talk about depressed people. I see the clinician showing through with sentences like "Depressed people are worse at simple sensory processing tasks..." The self-loathers will loath themselves more when they read that. You can easily re-phrase things compassionately, e.g. "Depressed people find it hard to..."
4. Avoid all-caps writing. Lots of people will read it as unprofessional. I think italics would work just fine.
5. Be sure to define your acronyms, even common ones like PTSD and DSM. I'm often surprised by the number of people who know nothing about PTSD. Plenty have never heard of the DSM. Perhaps you could embed some kind of pop-up definition?
Specific advice:
The short version: Do you want this to read like an abstract? You might take a different approach here and, instead of trying to list the things you cover in more detail later, just offer a few key takeaways that you want everyone who reads this article to see. I don't think you should list any medications in this section.
Simplify the "What is Depression" section. People will go straight for this section and they won't be prepared for what you've written. I think you could move a lot of the technical information to a subsection titled something along the lines of "How doctors understand depression" or "The science behind depression".
2.1.2: "But if you want secret/fancy things, the best evidence is... here". I'd rewrite the rest of this paragraph in simpler terms, eliminating the use of effect size (why introduce a new concept if you're going to talk around it?) and the discussion of good vs. bad placebo-controlled diet experiments. These sentences will confuse and derail the average reader. For someone interested in this stuff, you could include it in a more technical article.
"We still don't know much about nutrition... the researchers didn't check" is written in a fashion that will induce anxiety in anyone who is uncomfortable with uncertainty. I'd try out some alternative phrasing like "Research in nutrition is ongoing and will likely turn up new things in the future"
That said, I'm ok with how you express uncertainty regarding exercise in 2.1.3, therapies in 2.2, and supplements in 2.4 because those instances help you make your point.
2.2.1 Please include a therapy option for low-income people and those without insurance here. I don't know what the alternatives are in your area, but in mine (Southern Oregon), the low-income clinic offers really cheap therapy sessions where you're counseled by a therapist-in-training, and I know people who have benefited just from that.
2.3 If you don't have much advice to give about psilocybin, you probably shouldn't mention it until you do. I know too many people whose psychosis started with the casual decision to take mushrooms on a daily basis.
By and large, I think you've don a lot to make this piece accessible to a lot of people. Some of the most accessible sections were located later in the article. I think you could work to simplify some of the writing in the earlier sections, the sections people will likely read first, so your readers don't get discouraged early on. In general, I enjoyed it and I thank you for putting it together.
PS- Please including something about postpartum depression when you're discussing what causes depression. It's a big deal for a lot of people. I also know women who experienced unexpected depression during the hormonal fallout of a lost or terminated pregnancy.
This is an important point, especially given that postpartum depression comes at a time when time & energy are likely at their highest premium at any point during adulthood. Caring for an infant is a strain even for couples who have a healthy relationship & strong social support, much less single parents or couples with problems.
Thank you, a very nice guide as usual!
> In a study in India, , 40% of vegetarian women vs. 7% of omnivorous women had moderate anemia, a common consequence of iron deficiency (anemia is much more common in women, but some men can get it too). Symptoms of anemia include looking pale, feeling easily exhausted, feeling an urge to eat weird things like ice or dirt, and – yes – depression.
Extra comma + 2nd sentence repeats what was already said.
> The most-studied and best-supported supplements for depression is l-methylfolate.
supplements -> supplement
Is seasonal affective disorder a subtype of depression, or more of its own thing? I suppose diet/exercise and most of therapy recommendations apply regardless, but what about medication? If you have clear and stable seasonal patterns in depression symptoms, does it make sense to try melatonine as a 1st tier (instead of or alongside prescription antidepressants/5-HTP)?
Also not directly related to this guide, but I'd like to ask a question about vortioxetine. I have a relative who uses it because she was told that it does not tend to cause cognitive problems, unlike the cheaper options (even though money is an issue for her). Do you have any information about it? I think I've found an estimate that ~20% of regular SSRI users experience cognitive problems as side effects, but - in your experience - how bad these problems tend to be, e.g. at the median level (supposedly ~10th percentile of overall users) and 5th percentile (supposedly ~1st percentile of overall users)?
Also, I think the diet section would benefit from a clarification regarding soda: is its sugar content the problem? Should diet Pepsi be considered mostly harmless, or mostly like non-diet one?
There's summer-related depression as well as winter.
I'd have thought that lack sleep from the short nights was the big issue, but there are a bunch of others. Heat, disrupted schedules, body image....
https://www.webmd.com/depression/summer-depression
My anecdote is that zinc was life changing for me. I realized the only two times since puberty I wasn't suicidal were when taking zinc for my acne. Did some research, saw some links between zinc, estrogen, and depression. Ran an experiment. Never retested hormones because I didn't care why it worked just that it did. Most of the time I was taking 50mg/day, but I've tested and 25mg a day is the minimum for good effects in me.
August 8th 2016 (day I started taking zinc again)
Goldberg depression: 46 (representative of my life since 2004 or 5 or so)
Estridol: 37.8 pg/mL (Apparently a little high for a 22 y/o male)
Total testosterone: 624 ng/dL
Sept 27th 2016
Goldberg depression: 17
Feb 12th 2017
Goldberg depression: 13
I later found Prometheus claims I have a gene for poor zinc absorption. Also I've switched my opinion to my "true" diagnosis being cPTSD related to ways I was touched I didn't consent to. I still have some executive dysfunction issues I'm unsure what to do about and some anhedonia symptoms but I'm no longer an active suicide risk so that's neat
What I personally found missing in this otherwise quite extensive article is mentions of socializing. As a person with ~7 years of depression under the belt, one of the things that help a lot is making sure I don't stop meeting with people I like who like me. I think a (newly) depressed person might benefit of a lifestyle reminder that "if possible, keep socializing with people even if you feel tired, sad or useless, as long as people you're with don't make you feel worse". It definitely slipped under my radar at first
Typo: "if the medication give you" => gives you in 2.1
"ECT" near the end of 2.3 should be expanded to Electro Convulsive Therapy (or however it's generally typed) because it takes a second to recall what that means
Attractor state paragraph ("mathematical explanation") is probably incomprehensible for people who don't already know what you're talking about (I do, because I've read your stuff for a long time), and could use more links/expansion/a picture.
Could you annotate the article with references to primary (or other) sources wherever possible ? Maybe not at journal-publication level rigor, but perhaps at a Wikipedia level of detail.
Section 2.1.5 - I think it's very beneficial to
1. Give examples of very low goals ("wash your face when you wake up") so that people will feel that it's ok to go that low. Also because very depressed people might have hard time thinking on goals.
2. Encourage people to undershoot in their definition of success. It seems that doing something very easy consistently is better than doing something bigger but only 80% of the time. I believe it is because: It gives you a sense of accomplishment, it build an habit (see "atomic habits"), and finishing your task with energy, it's still possible to do more if you feel like it.
(Disclaimer: I think this post is really good overall! Just offering what I think is worth considering re: changes.)
Maybe consider explicitly flagging the potential for bipolar 2 to be mistaken for depression? One of my main personal experiences with depression is watching a friend be treated for depression for several years, then find out she actually has bipolar 2, switch medication, and improve some (it's hard for me to say how much).
My vague impression is that the bipolar 2 / depression misdiagnosis happens a lot, especially to women; and that people generally don't know about bipolar 2, because it's not "classic bipolar". If it's not actually common, then it's probably not worth including.
Probably the place to edit is "If you’re not sure if you’re bipolar, talk to a psychiatrist about it before trying anything on this page."
Thank you for this helpful and (like all your work) compulsively readable overview. A note about tone: I like a lot of the informal style (e.g. “The procedure itself is surprisingly non-scary”), which comes across as friendly and accessible, but (like others in the comments) I think you should be more careful about the ways you express uncertainty (e.g. “Maybe this should be a second-line option and I’m being a coward by putting it so low down”). In particular I disliked asides about secrecy (“Secretly I suspect…” “if you want secret/fancy things...”). I understand the desire to be honest about how medical knowledge is incomplete and developing, but I think it’s also good to inspire or maintain some confidence in medicine. Even when the doctor is saying, “Medications that are very helpful for some people do nothing for others, so we may to have to try several different antidepressants before we find the right one for you,” you want him to say it in a tone of cheerful competence that implies he knows the process inside and out and has a reliable system. “I can’t overemphasize how much great work by brilliant scientists has gone into this question, nor how totally useless and conflicting all the results have been” strikes me as funny, knowledgeable, and frank about uncertainty, while “I have never been able to get my patients to a high enough dose to test this; they get too many side effects and give up” is rather worrying.
For me, the idea that no one really knows what works or why it works and we’re just throwing powerful chemicals at problems to see what sticks is a major argument against psychiatry; I would need either gentle, patient explanation or despair of any other solution to be persuaded to try psychiatric medication, and any flippancy about the degree of uncertainty involved would increase my hesitancy. Probably it really is a free-for-all where the treatment you get depends on the idiosyncratic preferences and pet theories of your psychiatrist and nobody should get involved without fair warning, but to overcome anxiety as an obstacle to treatment, it seems helpful to increase the salience of knowledge and expertise and decrease the salience of experimentation and trial and error, insofar as that is compatible with honesty about the facts.
I agree with all this. As a psychotherapist I see a lot of people who might benefit from medication at various points but are absolutely terrified to try them, not surprisingly especially the folks who have anxiety in addition to depression. So a certain amount of cheerful confidence about giving it a try seems worthwhile, as does refraining from too much ambiguity-raising. At the point that a doctor is prescribing a specific patient a specific medication, there's appropriate room there to provide solid informed consent, including some of the equivocations and ambiguities. This article doesn't seem to me to be that moment.
I also find it helpful to discuss their specific fears (usually 'it will make me a completely different person' or 'it will make me happy like a zombie despite these bad things happening in my life' or 'it will make me addicted and even though I won't like it I won't be able to stop' or 'I'll get EVERY ONE of those side effects everyone rants about on the subreddit and they'll never go away' or a combo thereof) and realistic expectations.
Then also to emphasize that EVERY thing we try, including meds, is a single n experiment. If it doesn't help after a reasonable amount of time/dosage adjustment or you just hate it, you stop!
There's also an underlying fear, too, that needs to be addressed; 'What if I try meds and even THAT doesn't work? Then I'm really really doomed. So I just won't try them, so I don't have to experience that fear.'
Just for an alternative viewpoint: when I seek help from medicine, I really dislike the cheery optimism point of view. I'd much rather have my expectations set appropriately, even if they should be very low, and I would actually be reassured by informal signs that the physician was being completely candid -- which a touch of smartassery and revelation of his own struggles with the field provides.
This is probably not a useful opinion, as I've never sought treatment for depression, but I thought it might be mildy interesting in an academic way to observe that not everyone wants his physician to make an effort to be cheerful and optimistic. I sure don't. If his first impression on seeing my scans is to exclaim "Jesus! You'll be dead in 6 weeks!" I'd actually rather my physician blurted that right out. It can only get better from there.
This is so true for so many people, Carl! The artificial optimism and positivity is SO hard for any reasonable person to handle, never mind a depressed one! It's very helpful to give people realistic expectations or what can/will help and how much and how likely. I find it especially helpful to mention something like; 'well, given your symptoms and preferences, we'll start with this, and if this doesn't work, we can try that or this other thing and there are more options after that'.
Healthy optimism says 'there is probably something I can do to influence what is occurring and bring some improvement', not 'everything is or will be great!'.
Excellent, extensive and user-friendly article. A few more eclectic possibilities here... https://devaraj2.substack.com/p/dealing-with-depression
Weird thought: suppose we thought of depression as a weird form of prejudice or bigotry against yourself, in the manner of racism or sexism? Thats what the talk of global reduction of optimism and the need for raising your self esteem makes me think of. May not be a particularly useful perspective though.
I have experienced depression as anger held, and found that expressing anger healthily relieves my depression. And I note that anger is not mentioned here, which angers me slightly, so I am writing this comment.
I think this is my favorite comment.
This is a bit ambiguous: "Take 5-HTP 100 mg, increase after one week to 200 mg, increase after three weeks to 300 mg." Presumably means "increase three weeks after that to 300 mg".
I appreciate the importance you place on lifestyle change here. The resistance to it certainly is hard to overcome when underneath the weighted blanket of depression, but I can share a nugget of success:
I had severe treatment-resistant depression, more or less preventing me from holding down a job. We tried it all: CBT, escitalpram, buproprion, fluoxetine, sertraline, strapping magnets to my head, etc etc etc. The next step was ECT, and if that didn't work, the step after that might have been pretty dire.
So, I started volunteering at a local shelter, just one night a week. Very small ask of myself, and their sheer need for volunteers meant that there were no barriers to entry. It gave me a bit of accomplishment, a bit of self-respect, and some conversation ammunition other than 'I've been miserable in my apartment all week, thanks – how're you?'
They quickly noticed that I was invested in the work, and that I had time to spare, so I was promoted to lead volunteer, two nights a week. Slightly bigger ask of myself, somewhat more of a sense of accomplishment and self-respect. I started to build a bit of a community there, and weaned myself off my SSRI soon thereafter. It went well.
Bit by bit, I eventually clambered my way up to a management position, and have now been working there for three years. I have some bad days, but my depression is effectively over.
This plugs in well with your section on behavioral activation – the trick is making gradually bigger asks of yourself, which feeds your mental health enough to take the next, bigger step, until, whammo, you don't want to kill yourself even a little bit!
I found the stuff at the beginning about whether depression is just an emotion a bit misleading. In particular, it makes it sound like emotional states generally don't have real and profound physical and health effects. I mean, I ultimately think that the flaw is this idea that anything just in your head or your emotions isn't serious or doesn't require real treatment but wherever you identify the issue it seems mistaken to prop up the idea that emotions fall on one side of a clear divide and try and argue depression is on the other.
I don't know if I would change it since it makes sense to be more worried about people misinterpreting it in a way that is dismissive to depression but just my 2 cents.
> 2. Sleep problems (could be anything from having unusual trouble falling asleep, to waking up too early, to sleeping too long)
Isn't that a bit of a narrow window to squeeze through ? This sounds vaguely like getting anything other than 7.892 hours of sleep per night is an indicator of depression.
The way this gets described usually is recent changes in sleep or appetite. Eating or sleeping either more or less than is usual for you, the usual for you part being key.
As someone in a current depressive episode, I can only say that I found both the short and long descriptions exceedingly helpful for my current situation. Though my concentration is limited right now, I was able to follow the long description and skip to items that resonated with me in particular. I appreciated the amount of information; even though I have been grappling with chronic depressive episodes for years, my depressed brain sometimes convinces me that I'm not really depressed, so having the in-depth discussion of criteria and clear, precise ways to manage it were really enlightening, even to someone very familiar with the general information and treatments. I think what I appreciated and liked the most is that you very clearly articulated how hard some of the willpower-based treatments could be, but that even small steps are helpful. (Once I was too depressed to get out of bed, but I made myself clean the top of my nightstand. It helped. The next day I was able to do a little more. I use this method now when I feel too depressed to do much, and like you said, it makes me feel successful.) Personally, I've found DBT particularly helpful as a treatment, even though it was designed more for personality disorders than depression, but the skills are concrete and easy to remember, and I would enjoy seeing your take on it. All in all, I was grateful for the post and will be bookmarking for the future.
Also when you make claims like "On the cognitive level, depression is a global prior on negative stimuli." it sounds like you are defining the condition not offering an observation about what it involves. I mean I doubt that is part of the DSM 5 diagnostic criteria and it also has the potential downside of potentially confusing those of us who have been depressed but we're sufficiently aware of it to correct our best guesses about outcomes.
When my depression was pretty bad I could always tell my psych a reasonable probability distribution for what would happen if I took any action. It was just that the negative outcomes loomed larger and somehow were the emotionally salient aspect.
Also when you ask "1.1: Is depression caused by biochemistry or life events?" I know what you mean but it might help to make it more clear that you mean what is the factor that dictates who gets depressed .. I mean in a certain sense all mental events have biochemical causes but I'm probably just not picking now.
I only have things I wish you'd add, can't find any other fault.
Within your framework about depression as a neurological disorder with easy-to-notice mood effects, I was really hoping you'd spend a couple of lines on chronic migraines because I think there's a strong link there.
You make it sound like getting away from the depressing thing is only for people who have a clear sense what their depressing thing is. And while within depression it can be hard to identify, because everything feels depressing. But this is worth a dedicated investment of time and focus on. If you can't think while stuck in your room, go somewhere else to think about that. If you can think best while talking to people, talk to people or a therapist about it. If you can think best while writing, write it out.
The depressing thing can also be a lack of something, not something that is there. Lack of an important and worthwhile task, or lack of meaningful relationships, can be sufficient.
Pretty sure low testosterone can also cause depression, and is relatively easily fixed.
Not sure why you almost don't mention drug abuse. Maybe because you don't want to lie and say they never help, but saying anything else risks your license? Regardless, I think this is important. Most depressed people I know are abusing SOMETHING and depending on what it is that can change the situation a lot. Mood-altering drugs make the obvious mood-related components a lot less obvious, which makes depressive episodes easier to suffer through but also makes depressed people not seek real help. Illegal drugs make it MUCH harder to seek help.
Needs a section on pregnant and breastfeeding women, because their treatment options are different, they get depressed a lot and mothers are extra important.
Is it weird that my first thought when seeing MTHFR was to read it as "motherfucker"?
You are in good company on this.
Also re medication treatment I was very successfully treated by a psychiatrist (emminent addiction specialist actually) who ended up prescribing me Adderall and there are studies which back this up. I was eventually also semi-diagnosed with ADHD but even after 15 years or so the Adderall prescription for depression is still working great (tho no doubt getting older and married helped too). I don't know if you want to mention this since it obviously won't help patients to go be asking for it but it did work great for me.
I also appreciate how you remark about how ppl often give up but I think you might want to make a stronger statement on that. I know my tendency was just to take the meds the doctor gave me and not complain too much so even when Prozac was doing nothing for me I kinda just didn't want to cause a problem. I had a doc who pushed me on whether it was working and moved me on but that was a retired emminent psychiatrist and I know friends who just get lost bc they managed to get up the courage to tell a gp once get a Prozac script and then feel reluctant to complain. One of my friends even died thx to that kind of issue (semi-intentional opiate od...as in delibrate indifference and desire to die leading to risk taking).
I think that's something a number of depressed ppl struggle with (feeling like they are being a nuisance if they say still not better) so wouldn't hurt to mention.
Ohh sorry for comment spam but one other thought. It might help to give some sense of how much more helpful it is to also mention this to your doc than to just take supplements and tell yourself you are going to start execising.
I know that many ppl who are depressed are reluctant to tell a doc or ask for help (I was when I was horribly depressed and I let myself lapse into problematic opiate use rather than raise it with a medical professional until it all kinda fell apart) and I fear one common temptation will be to see all the diet stuff and use that as an excuse not to say anything to med pro.
That might be the right call for some ppl but I fear that the impression many readers will take away is: hey there is evidence for this diet and other crap and here is a psych spending just as much space on it on their website so it's probably fine just to do that and not tell my gp. I mean yes you say it's better if you have access but that's not until much later (many ppl won't read that far) and can easily be brushed off just as: well of course a doc prefers seeing a doc.
I'd include some stronger statement about the efficacy of treatment from a good psych over just trying to change your diet on your own. I know you probably won't be able to cite a research paper on that but nothing is wrong with just conveying your impression as a working mental health pro.
And more generally giving your personal sense of the relative usefulness of the various treatments would be very helpful.
In terms of mental health one of the best things I've gotten from your content was a layout of how you rated various treatments for anxiety in terms of strength/effectiveness (might be misremembering slightly). I mean those of us who can read sci papers but aren't docs easily end up with a bunch of papers saying X works or Y works but no real good idea (thx to high noise and different patient pops) what the relative effectiveness is. Ok so this diet helps some ppl but is that just as good as an ssri or just something that regularly helps a small fraction of ppl or a tiny bit but doesn't hold a candle to ssris.
Sorry one last thing. I'd love to see some remarks on anhedonic versus the other kind of depression. I don't know if this is the right page but I know that back in the day (15 years later might be different) when my doc talked to me about anhedonic depression versus other kinds I had trouble finding much useful online at my level which explained what that meant and how it impacted treatments etc.
If you are writing this to be read by possibly depressed and or anxious people... you might want to define stable (from the section about trauma in the 'do I have depression or something else')
"I would recommend worrying about the depression only long enough to make sure you’re stable, and otherwise putting your effort into pursuing therapy for trauma."
You know what you mean, but your reader may not. Part of the joy of your writing is it is clear, and often rises to making complex ambiguous things not ambiguous, like the adjacent 'look stop trying to decide if you are more depressed or anxious, just get you depression-anxiety treated; bit.
A depressed or anxious person (or somebody who knows one to the point they are reading your web page about depression) may be wondering, or may need to be wondering, if the depressed person is 'safe' - and if they are not, what to do. I recognize safe is hard and crisis is hard and you probably cannot write to that without clinical evaluation (and perhaps not even then easily) but when I read 'stable' it filled my head with questions.. do you mean not suicidal? Not bipolar or suffering from wildly changing levels of depression? Not... what? ... all of which is a close proxy for 'safe'.
When I was clinically (and situationally triggered) depressed/suicidal, I got real close to actual suicide before I and others around me recognized I was not only not stable I was not safe - something I should have recognized earlier (except I was, you know, depressed) and something those around me might have recognized earlier (except, of course, I had been depressed for a bit and therefore not acting normally / masking my depression / they were the trigger of my depression and were dealing with their own depression and issues / etc).
If you haven't experienced it before, you may not know when you have crossed the line between great, ok, sad, depressed, and DANGER! ACT NOW! - having been through that journey once, I feel like the odds I will recognize 'oh shit I am feeling/not feeling that way again; plus be willing to ask for help, even significant intrusive scary help like hospitals and leave from work and such, are much much greater. I worry how to communicate that effectively to other who haven't been there seen that before...
- My own experience for context: my mom died of cancer and some other bad/tough stuff happened to my family, and then we had a baby. For somewhere between several months and 1.5 years, I was irritable, unmotivated, not much enjoying things, sleeping too much, and drinking heavily most every night. My wife told me she didn't think I was okay and asked me to try therapy, and I was resistant for a long time. Now, due to some combination of time, lifestyle changes, and therapy, I'm doing rather a lot better. The points below are based on some of what I can see in hindsight were challenges.
- If you are some combination of analytical/knowledgeable about psychology/used to being self-reliant, you may have some resistance to a "diagnosis" of "depression" - if folks close to you think you need some help, consider the possibility that they are seeing something you don't and that getting some kind of help might make sense
- Also, note that the depression-related pessimism might strike here as well: you will be less likely to think that treatment will be helpful and more likely to think that it reflects badly on you or others will think less of you for seeking treatment.
- Especially for depression brought about by a life event (like grief over the death of a loved one), know that it might take some time and that intellectually "understanding" what has happened is not the same as working through the feelings and associated physiological changes caused by the event. This can be especially troublesome if paired with the resistance to help above: you are "fine" because you've "dealt with it" on an intellectual level, which makes you even more resistant to seek out help.
- Building further on "whatever lifestyle change you will actually do", consider lowering your standards of what "counts" radically, as low as you have to to get to something: for example, you might want to do some fancy combination of high-intensity cardio and weight lifting, but you're having trouble getting out of bed. Going for a nice, easy walk while you listen to some music or a podcast might be an easier sell. With diet, rather than going for a strict modified Mediterranean diet, maybe just make sure you eat some salad once a day. You can always ramp up later, and getting something you can do consistently is more useful than getting it perfect for a few days and then finding it too hard to stick with it. You make this advice clear in your specific regimens, but as a general rule for behavior change, I've found "make it so easy you can't not do it" to be really helpful, especially when feeling unmotivated/depressed.
- Anecdotally, I've had some good results from hot and cold exposure, though hot exposure (sauna, bath) seems better for relaxing when feeling anxious (unsurprisingly), and cold exposure seems better for dealing with lethargy/lack of motivation (again, unsurprising). I've heard that there might be some studies to support this, but no idea if they're any good or what they are. I also know ice baths were a treatment for depression back in Victorian times, which was not too long ago was seen as senseless barbarism, but now some folks are like "maybe they were on to something". Wim Hof has a good program for easing into cold exposure through incrementing up how much time per shower you spend with it cold: https://explore.wimhofmethod.com/coldshowerchallenge/ . These benefits might partly or wholly be of the "I did something intentional to help myself" variety you discuss
- Take note if you are "self-medicating" in some way: common forms include frequent and/or very high consumption of alcohol, pornography, or other things that reliably create short-term feelings of well-being. This can be very sneaky: you may just feel like you "like" the substance/activity. Again, if folks close to you are concerned about it, that's an indication that it might be more than just "liking" it.
+ I see you mention psilocybin, but very passingly, for obvious reasons. My own experience is that taking psychedelics a few times, several months apart, in increasing doses, was remarkably helpful in mostly stereotypically hard-to-describe ways, but the most obvious was making it blindingly obvious that my intellectual understanding of the situation was not the same as processing it emotionally. You might point out that anyone who lives near Johns Hopkins or other universities/hospitals conducting such research could check to see if they are accepting applications to participate in studies
- Minor point: regimens 3A and 3B do not list energy/time budget, but I would guess it is "high" after the low and medium above
This is a lot of hard-earned wisdom right here, well said. Especially that intellectual understanding does not equal working things through, that our loved ones can sometimes see better than we can that something worrisome has settled in, and that radically lowering (or expanding) notions of what "counts" is really important.
Thank you for a wonderful summary and helpfully curated literature links!
I think the structure of the piece is excellent, and flows logically. It is indeed a difficult read, particularly for a depressed individual, but the subject is complex. I think it would be a mistake to dumb it down.
I love that you love tricyclics and MAOI! These agents are woefully underutilized.
It is my conviction that TCA are superior to all post prozac antidepressants for the treatment of panic attacks, and for that reason should be considered a first line agent for patients with both panic disorder and depression. Alas, I have only anecdotal evidence to support this assertion.
A related point, I would suggest you consider distinguishing panic from anxiety disorders in general.
It occurs to me this would be a great resource for concerned family and friends. Perhaps adding some links to resources, as well as suggestions on how to deal with a depressive in one's midst, might be a boon.
Other treatments not mentioned which have at least single or even multiple case report level citations in the literature include:
Modafinil augmentation
Core body temperature elevation
Augmentation with anti-inflammatory agents (which leads into the novel area of research of depression as an autoimmune disorder).
low dose buprenorphine
Your work on this constitutes a great service, potentially helpful or even life changing to many. Thanks and praise are due you.
The first time you mention omega-3s, you say "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."
However, the second time, you link to vegan and nonvegan capsules (which it looks totally reasonable to get 2g/day from), and describe "one pill/day [as] being a low dose and two/day [as] being higher" for the nonvegan option (whose pills are 605mg each - the label says 1210mg/serving, but a serving is 2 pills).
1.1 and 1.2.1: Are “depression”s associated with stressors and “depression”s not associated with stressors a single psychopathology or two (or more?) psychopathologies with similar symptoms? If a patient with psychological and/or physiological stressors is less likely to respond to medication, does that suggest the latter?
My bet is that there are multiple pathways to a set of symptoms that we call depression. And severity also alters what it looks like and how effective meds will be (more severe; more likely meds will help).
Meds to help people w/very good reasons to be depressed; I've commented on this somewhere. I wonder if there's a way to search the thread ....
In the business of prescribing different kinds of physiotherapy and doing some manual therapy myself I had to get to terms with classical massage treatment. Many people with pain issues wanted it prescribed and the insurances in Germany preferred active physiotherapy a lot. For many orthopaedic problems there are much more efficient hands-on therapy choices. The evidence said there was one sound indication for classical massage treatment: depression. Last time I checked, that hadn't changed. From an evolutionary perspective it makes sense to me. Other social primates fumble each other most of the time and those that get fumbled most happen to be the healthiest overall. They also happen to be highest in their hierarchies which may not be beside the point.
Anyway, if my schedule of training, meditation, work, personal encounters and beer should leave me too unhappy to bear it, I would get a lot of massages before taking any drug that hasn't been around before the industrial revolution.
Great write-up! I only have two comments of note:
1. Consider turning your list items into an actual list format, and bolding the list item itself that you're describing (e.g. the drug name in the drug list, the supplement in the supplement list, ...), that should make it easier to resume reading in case one is dragged away from reading for any reason.
2. I'd personally recommend people with access to a doctor should check themselves for deficiencies before taking anti-depressants. My B12 deficiency that I keep harping on was one that nearly went undiagnosed to terrible effect, because no one thought someone under 35 years of age who wasn't vegetarian/vegan would have it, and I didn't have a corresponding folic acid deficiency, so the symptoms were masked. Meanwhile I was gradually getting dementia. I was very, very miserable, despite somehow mustering up the desperate energy to rearrange almost everything about my life (it was so, so hard - and it definitely had large payoffs, but the largest chunk was just the deficiency).
Two very minor comments:
(1) In 2.3, after you recommend ECT after your third-line options, put a "(see section X.Y.Z below)" call-ahead. Reading it, I was wondering whether you were going to go into more detail on it. You did, but not until a couple sections later and if I was cherry-picking a section to read I might miss it.
(2) In 2.6, add the doctor access and "high time/energy budget" to 3A and 3B. Sounds dumb but my brain wants it there for completeness.
I found it a good read at the right level for me and my bubble (mostly grad students). FWIW, if you end up making a less vocab-heavy version as some commenters mentioned, could you keep this one somewhere too? I feel like I know people who will be skeptical of any depression description that *doesn't* describe it at the level you're doing.
Regarding the bad thoughts component of depression, something that helped me with feelings of guilt specifically were parts of the Replacing Guilt sequence by Nate Soares. It's at http://mindingourway.com/guilt/ or mirrored at https://forum.effectivealtruism.org/s/a2LBRPLhvwB83DSGq
Nowadays I can still feel bad, or lethargic or something, but I hardly ever feel *guilt* for things I consider outside my control, like not meeting my own or anyone else's standards during moments of illness or fatigue.
For a fair-minded and fairly brief discussion of the history of electroconvulsive therapy that doesn't take sides, I would recommend Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky. It's a psychiatric history book that doesn't portray psychiatrists as moustache-twirling villains!
Typos:
2.1.2.1 Spelling: change refridgerator to refrigerator
2.1.5 double word: change enough enough to enough
Overall I think you struck your desired balance of pointing out good studies, anecdotes and your personal opinion.
You don’t mention postpartum depression at all. Even if this is a whole other subject it deserves a mention.
Section 2.3
It’s a good no nonsense overview of medications and what you recommend in your practice.
I think you should add a comment on the time that is needed for “trying” antidepressants, i.e. how long they need to be taken to determine that they work, weaning up, wean off period and then another wean on period, large ballpark is fine. This may fit well when you mention first, second, third-line strategies, etc. or more specifically stated in section 2.6 (instead of gleaned from the scenarios) or 2.7 and putting a reference to that section in 2.3.
You gave time commitment figures for the ECT and TMS, which was very helpful. I’m currently in this process and have been for 10 months. It's very long and frustrating. When deciding to start medication, I found it difficult to get a straight answer from my psychiatrist(s) on what to expect. My guess is that they didn’t want to make any promises so I wouldn’t get disappointed. I wanted best case and worst case scenarios so I could measure my expectations. I had no problem with the caveat that we don’t know because every person is different, but only being told let's give it 2-3 weeks before we make a call was frustrating. It’s a constant struggle to continue to fight the depression. Having realistic expectations for how long finding the right medicine could take would have been helpful. Depending on your audience, this information may not be needed. My experience and those of my peers (20-30s year olds in the biological research arena) and any family member I have discussed this with, antidepressants are scary and we don’t know much about them, especially real world practice (like 2.7, I really liked that section). Setting these expectations correctly from the beginning goes a long way.
And time frames for therapy as well! If someone is attending regularly and participating as suggested (ie doing homework for CBT, trying new ways to deal with people in interpersonal therapy ....), they should START to experience improvement within 3 to 4 months. If there is no noticeable change for the better within 6 months, it's time to change approaches and/or change therapists and/or add medication to therapy.
And if the person is so depressed that can't do what therapy suggests, even when goals are realistic (ie, doing a little bit more than you're doing now, the re-evaluating that if it's too hard to do ...), then also time to consider a different type of therapy or adding medication/changing medication.
Scott, because you recommended magic mushrooms, I think you should also recommend LSD. I became quite depressed over the course of the pandemic and ended up reduced to staying in bed 80% of the day and constantly heavily drinking. I read your post on depression as an attractor state, then resolved to take acid and instantly adopt a bunch of lifestyle changes. Within a day I returned to something approximating my pre-pandemic self and started cleaning up all the life problems I created by being too depressed to do anything for six months. I cannot stress how great it was enough. It was like the acid gave me the tool box to just delete depressive thought patterns from my brain.
There is one question which is extremely conspicuous by its absence:
Should I try to treat my depression at all?
Seriously, treatments for depression are horrifically expensive, and not just financially. Therapy will cost you thousands of dollars and tens or hundreds of hours of your life. Anti-depressants will kill your sex life, make you fat and unhealthy and disrupt your sleep. Exercise and diet changes may be generally good, but you already knew that before you were depressed and didn't do anything about it then.
There is in fact another option: do nothing. Sometimes this even works and the depression resolves itself spontaneously.
It usually does resolve itself spontaneously, mean duration is around 6 months for a first or second episode. BUT there is often a huge price to pay in the meantime/as a consequence. Deterioration in interpersonal relationships, looking incompetent at work, flunking important courses/a whole semester ......
I usually tell people to give it their best efforts in self-care and seeking extra support from those who are about them. If they're heading past a month or 6 weeks without improvement, time to get help.
And of course 6 months is an average; often it lasts longer, or the consequences perpetuate the depression ...... And of course, if there IS something that will help and you can access it, it's a good general rule to reduce suffering. Being even moderately depressed is extremely painful.
I'm not arguing for it as the best option, certainly not for everybody, but it is an option.
The reason for pointing this out is that there is a fairly general bias in medicine towards treatment, any treatment that is not no treatment. Regardless of whether the treatment is a net benefit, we must do something to treat! Sometimes this is justified, like, "left untreated, this kind of cancer will always spread and kill you." Many times, it is not.
In the case of depression, do-not-treat is an option worthy of serious consideration, particularly given the side effects of the most common medications. The above presentation of depression does not even mention it, without justification.
That's why I don't like that many MDs default to 'oh, you're depressed! Here, take this medication ...' without even discussing other options with patients. While improved self-care and support-seeking and psychotherapy are not always benign, they mostly are, and often very helpful with few undesired side effects.
Here in Canada there has been a big problem with availability of non-medication options for anyone not able to pay for private care; not only not easy enough to access, but also big variability of what people can get, from province to province and from urban to rural and remote regions. Provincial gov'ts (responsible for health care) are starting to smarten up. Mostly because every $ spent on therapy and other supports saves them multiple $s elsewhere in the health system, but hey! We'll take it!
"Should I try to treat my depression at all?"
If you can still function and can handle the level of unhappiness or numbness or "everything is grey, I used to enjoy doing this thing but now I can't do it anymore", then sure, let it be. You can get used to feeling horrible all the time. People around you will get used to the new you or drop you - you're not the spouse or partner they fell in love with or the friend they used to have good times with anymore, they're not obligated to stick around the dull, silent, zombie.
Depends what you want out of life. If you can stick with several years of being like this, go ahead. Maybe you will decide you hate feeling this way and want to break out of it, maybe you'll just go on that way.
If people do want to change, Scott's advice is generally good.
This is a beautifully comprehensive, well-written, and helpful summary. I know some people who will benefit from this, so much appreciation for the time and energy and care that went into it. Since you asked for comments, I have a very few:
You call synapses "wires." Can you rephrase this to emphasize that they are junctions, connections? It probably doesn't matter to most people, but it reads weird to me.
You refer to a few amino acids as "chemicals" and I think it might not be bad to indicate that they are naturally-occuring amino acids, a regular part of the diet anyway, so you're not introducing something *new* to your body chemistry. That might matter to some people (it would to me, for example). And for those people who prefer to get it in a more natural way, they can go look up in what foods you could get extra tryptophan, for example.
In your discussion of CBT, and maybe therapy generally, one aspect I didn't really see covered quite as much as might be helpful in some cases is the degree of disordered thinking that is part of depression. One might think this is one of the foundations of the idea that CBT (or therapy) can help: that it may be possible by conscious effort to retrain your mind to have different habits of thought, which can help, on the grounds that some aspect of depression is misinterpretation of experience, i.e. a cognitive failure.
The reason I mention this is that I have known people who see therapy as just a mission of discovery. If I discover my mother was cold to me from ages 1-3 because of blah blah that was going on in her own life -- hey presto! the depression will go away as soon as I have this insight (and if it doesn't, that means I need some more insights -- different therapist, or another book from a best-selling author). I feel like the idea that discovery is not enough by itself, that there is work to be done to retrain your thinking patterns also, might be helpful to emphasize a little more in the context of discussion therapy. You certainly do mention it at various places, but it doesn't seem as connected to the therapy option as might be helpful, especially to people hoping that if they go to the therapist and just listen attentively, he's going to give them some explosive insight that will Fix Everything shazam -- and if he doesn't, he's a terrible therapist and/or therapy is useless.
Obviously I'm thinking of people who do not yet have a grip on their depression, and are not right now under the care of a good psychiatrist who would make all this clear -- but I am assuming these are among the people you most want to reach and help.
I found the introduction of attractors a bit weird, since they pop in but do not inform the rest of the discussion, and unless you are interested in signaling to physicists or mathematicians that you grok them it doesn't seem to do a lot of good. I wonder if you could use some more accessible analogy, like a pit with slippery sides, to emphasize (if this is what you're doing) that sometimes it's 2 steps forward 1 back, that is, that recovery from depression may not be a smooth path -- there will be setbacks, which should not be mistaken for complete failure.
Weird point but while I love the term "priors," I don't think it's gone mainstream. Meaning, I'm not sure the majority of normies (including depressed normies) would natively understand what priors were unless you explained it upon first use.
'Last ditch' for ECT felt like an insensitive choice of words, even if accurate?
I'd add two things I think are important, and relevant enough to enough people to be worth including;
- New or greatly increased irritability and/or agitation can also indicate depression (more commonly seen in men, and probably one of the reasons men are less often diagnosed with depression).
- When depressed and considering/seeking therapy, it can be very helpful to consider whether this depression appears to be dominated by negative thinking, or by distress over interpersonal relationships (family, romantic/sexual, friendships, at work ....). If the thinking, then CBT will most likely be helpful. If relationships, interpersonal therapies and/or insight-oriented therapies may be most helpful. We can't directly change the people around us, but we can change how we deal with them, which can lead to improved relationships, or less distress in non-improved relationships, or more ease at getting out of/away from distressing relationships. HOWEVER, interpersonal/insight therapies are harder to learn to do, so getting a recommendation and/or talking to several therapists before deciding and/or looking for a therapist with a higher level of training becomes more important. BTW, the result of the therapy (and perhaps the source of its efficacy) may be that the person then manages to implement Scott's recommendation of changing the life circumstances that are making the person unhappy; this is often very hard to decide on and carry out!
I thought it was engaging and helpful. I especially liked the Mediterranean diet chart, links to specific supplements, and other concrete things like that. I often become paralyzed by trying to optimize, or mired in product comparison, so I appreciate how actionable this is.
I think you should add (maybe after detailing symptoms of depression) that if you think something might be physically wrong with you but your doctors keep telling you that you're depressed, document your symptoms and seek additional opinions. Many people with less common conditions spend years misdiagnosed or undiagnosed and being brushed off with a depression diagnosis is common. I eventually turned out to have ankylosing spondylitis, and Enbrel was on another planet, effectiveness-wise, from bupropion, even though bupropion gave me the energy and ... I don't know, cheery-optimism-ness? ... to push through a few years of pain and fatigue which is not nothing! But not an ideal replacement for accurate diagnosis/treatment.
Furthermore, I can tell you from personal experience, once that first diagnosis of depression or anxiety is in your chart, there's no limit to what symptoms some doctors will attribute to it. I once went to the ER because I couldn't catch my breath, felt like there was something in my throat blocking air, and was coughing up dark red chunky stuff (sorry for the image.) I had been sick with a cold for awhile, had laryngitis, and informed them that I was on immunosuppressant drugs. They say, oh I see you have anxiety, do you get panic attacks a lot? I say no, and I don't feel panicked, just concerned about this blood I keep coughing up. They spent an hour having me to do breathing/calming exercises, somewhat reluctantly got a chest x-ray and then said oh, huh, you have pneumonia. Which did not surprise me, because I was *coughing up blood.*
I will say that when I was actually definitely depressed, I did an online CBT workbook called MoodGym (don't know if it still exists). I thought it was dumb, expected it to not work, and felt stupid the whole time I did it but actually it seemed to work a lot. So on the paraphrased grounds that effective treatment is that which, when you don't believe in it, works anyway, I give CBT high marks!
My biggest piece of advice to someone depressed or otherwise ill in a way that makes you tired/forgetful/struggling to accomplish things is that if you have the option, ask someone else to handle the doctor-finding/insurance-calling/form-filing stuff. It's too easy to hit snags, run out of energy, and just end up delaying treatment for so long but it's insidious because it seems like it should be easy, like you shouldn't need help, you'll just do it tomorrow. If a partner/family member/friend is willing to help in that way, it can make a big difference.
"They spent an hour having me to do breathing/calming exercises, somewhat reluctantly got a chest x-ray and then said oh, huh, you have pneumonia. Which did not surprise me, because I was *coughing up blood.*"
That is the part that constantly amazes me. You show up at the hospital with definite, recognisable symptoms - it's not just "uh I feel a bit wonky", your pulse rate is off the wall or you are literally blue in the lips or you are crying with pain, and you get handed two paracetamol and are told "go home and calm down".
I was in the same boat - luckily, not pneumonia, but it wasn't until the chest x-ray that the doctors did go "oh, you have fluid in the lungs; turns out you have a respiratory infection, here's a prescription for antibiotics" where up until that they had been "just go home and calm down".
The irony was that the ambulance guys (I had to call an ambulance to get me to hospital) had told me, on the drive to hospital, "oh yeah, sounds like a respiratory infection, that's why you have [these particular symptoms]". Had they been the ones in charge, I'd have been turned around in about fifteen minutes; with the doctors, it took about two hours of cooling my heels until THE OBJECTIVE EVIDENCE OF THE X-RAY and not, you know, the patient complaining of elevated heart rate and inability to breathe, convinced them otherwise 🙄
I've heard that having clear symptoms ignored is more likely to happen to women and poc.
I suppose unclear symptoms (pain with no obvious source, exhaustion) are likely to get ignored regardless of who has them.
Still ignored more frequently in women and BIPOC people.... sigh.
To some extent, this was intended as a prompt for people who have accounts of doctors ignoring obvious symptoms in white men.
As someone who has worked extremely hard to make lifestyle changes to fight depression and PTSD, I liked that you did not overemphasize medication compared to lifestyle changes. I think people too often will self-describe as having genetic depression to avoid having to do the work to fix their problems or to validate their difficulties. I think also there is a trend for people to try to get a diagnosis of something they consider more genetic than depression for a similar reason. People often fake/overexaggerate PTSD or bipolar (especially bipolar II) to make their problems seem more justified, even though depression itself is difficult enough.
It's sort of a catch 22 .. life style changes are hard, they require substantial willpower and dedication, its hard enough for "normal" people. most people i know that suffer from depression have extreme difficulties in exactly these areas (including me some years ago).
So yeah, i know it works, i was able to change my life in a very fundamental way (i stopped drinking, "dry" since 4 years now, i dropped 40kg, started working out, fundamentally changed my diet, I did a real u-turn), but i also know its hard. I'm sure there are some that use genetics as a cheap excuse, but after all .. some people are weak, and to change your life you have to be strong.
RE: Treatment algorithms & medication: I would suggest adding a bit on what first, second and third line strategies entails. For example, the different lines represent a gradual decrease in common usage and/or proven effectiveness or an increase in potential risks. My reasoning is that some readers may think that the third line are the 'big guns' and jump straight to those, especially medications that could be obtained without the potentially-threatening step of consulting a doctor.
Isn't ability to form synapses directly linked to intelligence and cognitive abilities? Does depression make people underperform on IQ test for neurological reasons?
Yes it does, for whatever reason.
I'm curious specifically about neurological reasons. Underperforming on tests because you are feeling bad is understandable.
Nope, they underperform because their concentration is terrible and their memory is not great, especially in severe depression. It's not primarily emotional; people who are extremely upset or unhappy can still do as fine as they normally would on IQ and other neuropsych testing.
Thanks. Do their cognitive abilities recover after recovering from depression?
Completely! Which, as you can imagine, is a huge relief for them.
I'm not a psychiatrist, nor do I have depression, so I'll only review for style and clarity.
In general, I think this writeup of depression is clear and informative. It has succinct summaries of the state of the field, and simple, concrete suggestions that people can follow. I like the Q&A organization because depressed people with no motivation probably find a wall of text more intimidating than ordinary people, who already hate reading walls of text.
Specific comments:
"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 is way too technical. There are intuitive ways to explain this concept that don't require an advanced education in chaos theory.
"(my third- tier suggestions weren’t studied, because the researchers were cowards)."
Your ACX readers know you're being light-hearted, but your first-time patients might not, and might think you're being very unprofessional in accusing researchers of cowardice for not following your suggestions. I think you should remove all instances of "coward" or "cowardice" except when you're describing yourself.
Regimen 3A/3B: you forgot to say who these regimens apply to.
I generally thought it was excellent (for an audience with sufficient reading comprehension skills) but the "coward" bit really stuck out to me as well -- it's probably both unhelpful and off-putting to tell depressed people that their psychiatrist is a coward.
What lead you to update your beliefs about Effexor vs. Cymbalta? ( Here you recommend Effexor https://slatestarcodex.com/2015/07/13/things-that-sometimes-work-if-you-have-anxiety/ )
This article is superb in many ways, but the main reason I feel compelled to contribute to the discussion is that I strenuously disagree with the comments suggesting an excess of academic language and complex ideas. I have two main objections to this point of view.
Firstly, I strongly believe that bridging the gap between scientific research and public discourse is crucial, and I think you strike a good balance here. But there's another advantage to disseminating these complex ideas which is less frequently remarked upon. People respond to models of depression that for whatever reason connect with them personally and give structure to their experience. Sometimes this is pernicious, because it may account for the effectiveness of pseudoscientific treatment. But it can be extremely useful, and the more such models that are out there, the better. For example, the section on depression as an attractor state in a dynamical system was fascinating, and I'd very much like to know more about it.
Secondly, there is a dearth of resources on depression for highly intelligent people, which makes it extraordinarily difficult to seek and consequently remain in treatment. Among other things, this is an enormous social problem, as the intellectual resources available to us as a society are eclipsed by depression in high IQ people. An opportunity to engage intellectually with the topic is extremely valuable, and I therefore emphatically discourage the removal of any academic material from this piece, on account of the rarity of the resource you've provided here.
This leads me to a final remark, and something I've often thought of. You mention that much of CBT "sounds and feels obvious", and that its advice has become cliched. This is a powerful deterrent, particularly to people with high IQ and major depression who are even more subject to the illusion of rationality that comes with the illness. And you are, of course, absolutely correct that the practice of CBT principles is what makes them useful. There has to be a better way to address resistance to it: a better way to communicate its advice and emphasize the necessity of building the routine.
In conclusion: if anything, I'd expand on the areas I've mentioned, perhaps with the addition of an acknowledgement that these ideas may be new and difficult, if you feel that the comments on the piece being too jargon-y are justified.
I agree about keeping this piece at an intelligent reading level. As I've mentioned, a lot of patients have to "dumb themselves down" when going to the doctor, particularly consultants or specialists (who seem to take it as a personal challenge and affront if you speak to them on any level above "oh doctor I have a really bad pain in my tummy") so the estimation of 'what people can or will read' may not be at a true level.
I found the use of "coward" somewhat off-putting and in some instances unclear. I also wonder if it might not be triggering for some depressed patients in the same way that "worthless" or "weak" could be.
This is beautiful; thank you for writing it.
1. Some upfront, visually-oriented, exec summary or graphic would be helpful, especially if it provides 1-3 sentence answers to each of your questions.
2. Am curious about answers to the following questions --
a. "A loved one is depressed. What should I do?"
b. "I am >= 90th percentile depressed. At best, I can perhaps summon the energy to do exactly one, low-effort thing. The alternative is giving up. What is that one thing?"
My guess after reading is some version of -- call a hotline and get help. But that's an inference.
c. "Should I lose 10 pounds before everything else here?"
Thoughts as I was reading:
"Consider exercising more and adapting a modified Mediterranean diet."
Should this be "adopting a modified"?
Re: some illnesses cause depression, some others have mentioned low testosterone which is now being implicated in depression, especially for older men. Might be worth a mention.
Re: 1.1: Is depression caused by biochemistry or life events?
The attractor paragraph seems pretty impenetrable. I suppose it depends on your intended target audience whether it's actually illuminating at all.
"This is one reason I continue to wonder if the sense of accomplishment and getting outside is as important / more important than the exercise itself."
I'm inclined to also think that it's partly mindfulness at work. Exercise and stretching both require focusing in the here and now, which distracts from negative thought patterns.
"If you have zero willpower, not enough enough to be the seed for a tiny investment"
Duplicate "enough".
Re: omega-3 supplements
Perhaps it's better to recommend brands that have IFOS certification. Some consumer reports analyses found that many omega-3 supplements were poor in EPA and DHA, and many even had considerable contamination with heavy metals. The supplement industry is brutal.
Re: 2.6, good idea providing examples of specific regimens. I think people are generally better at generalizing from the specific, rather than deriving a specific instance after learning a general rule. A set of mashups of your suggestions should give a good feel for how recommendations should be applied and how they interact.
It seems strange to classify tianeptine as a supplement rather than as a medication.
Bit late but "I think it’s barely worth clearing up confusion between depression and anxiety." in section 1.2.1 and "Second, make sure your depression isn’t caused by some other issue like insomnia, drug abuse, anxiety, etc." as a step in 2.6 seem to me to at least be slightly confusing, as the first seems to suggest you should go right ahead and try depression-related treatment if you might have anxiety-depression but the second seems to suggest you ought not to do that.
Really enjoyed it—these Lorien articles have all been extremely clear, entertaining, and useful.
I'm currently on Wellbutrin, 450 mg per day. I started on 150 and worked up to 450 over two weeks. My psychologist says this is a very heavy dose, but apparently my case warranted it.
It's doing something good, at least.
Minor suggestion:
Section 2.6: "First, check that you don’t have bipolar disorder – if so, you will..."
Suggest change to: "First, check that you don’t have bipolar disorder – if you do, you will"
just to be a little bit more explicit.
" we can't get it it into your brain except by drilling a hole in your skull and injecting it directly"
This seems like a thing people should try, I don't really know but I feel like it's worth the risk for extreme depression.
It may be worth linking Robert sapolsky Stanford depression talk in there.
I absolutely love his soothing and interest piquing lectures, but how did they stand the test of time?
He mentions priming studies a lot, for example :/
As recently as last year too :{
I agree with other responders that this guide is really, really useful.
Adding more information about the interaction of other disorders with depression could be really interesting. As I read comments, I see people interpreting their "depression" symptoms in the context of symptoms of (possibly subclinical) other things. Since, as you state, depression-anxiety is a common pair, a section like "if you have these situations then you may be dealing with depression-anxiety" or "if you have these situations you may be dealing with depression-ADHD" et cetera could be useful for people who might not recognize themselves in the symptoms otherwise. For example the "freeze" state which comes up, in which the anxiety "oh no" creates a feedback loop with the depression "everything is bad" and makes it much more difficult to either calm down and change perspective (overcome the anxiety to address the depression) or cheer up in order to do relaxation and calm down (overcome the depression in order to address the anxiety.) 800 mg of ibuprofen and a couple magnesiums on a situational basis have been useful to me for this. I was recently prescribed prednisone for a couple of days for something non-mental health and felt happier than I had in years, too bad it ended. I am also a big fan of the hydroxyzine/cetirizine medications, if I am jittery because I ate peanuts or drank coffee, it feels like everything is falling apart and life sucks, but no amount of thinking about it makes a difference, but the anxiety/allergy pills knock it out until my metabolism can clear the irritant. I was in my thirties before I noticed those food sensitivities and wasted a lot of time miserable.
The depression - ADHD feedback loop goes something like, what was I doing, oh dammit I can't put this together (feelings of worthlessness), nothing makes a difference, it will never work, things are getting worse, I'm incompetent and nothing I try works out right (forgetting in the middle of every self-help strategy), distraction and failure pinging back and forth. I think ADHD meds are the key out of that one. All of that will look like "depression" but the reader experiencing it might not recognize themselves.
Do ADHD versus PTSD next!
Also the posters who mention the "dual diagnosis" side of depression plus substance abuse or depression plus substance use have a good point. This is dated information but the stoners in my high school were pretty open about their self-medication and condemned the establishment as useless; these people were far easier to access than quality professional mental health care and while the DIY approach was admirable there was often at least one weird element about their self-medication. Supporting their healing journey felt about a millimeter away from enabling them checking out mentally. Fortunately with the advent of legalization in many places it now may become easier to address; yes, your level of use and strains of use appear to be helping your symptoms, or no, your use is numbing you out while restricting your ability to manage your situation.
How many drugs their friends do may actually have a significant effect on what steps someone takes first when they feel they have mental health concerns. People with good connections may start with high-quality weed and move on to microdosing, bypassing SSRIs entirely, feeling empowered the whole time. People with no or bad connections may be more likely to use booze, occasional low-quality weed and then wind up in "therapy," feeling confused. At that point they are reacting not only to their symptoms but to their past experiences of self-management that didn't work. Which door someone opens first will determine a lot about the subsequent experiences - also, how they react to hallucinogens if they use them - and addressing that would be interesting. I don't microdose but when I look back, the people who I knew who were for example on shrooms at school or tripped every weekend were more resilient longterm than the ones who were drinking and that was dependent on friendship group (may have been some self-selection). What the support network is makes a difference although at the time I think the drinkers were considered more responsible. I hope the medical establishment can assimilate this, I think ketamine is a start. I think people do lie to their doctors about drug use and these patterns exist but might be hard to find in research.
On exercise and depression: Article by a guy who wrote a book about running and mental health on how/why US healthcare system doesn't recommend exercise as first-line treatment for depression when many other countries do: https://getpocket.com/explore/item/running-from-the-pain?utm_source=pocket-newtab
A humble request: Please provide links or write more about this statement: "several studies have found that therapy from a book, or off an app, or via some other kind of course, is just as effective as therapy from a professional therapist." Or maybe you did already at SSC? Any pointers you have would be much appreciated.
I somehow got linked back to your intellectual progress of the 2010s post and it includes this relevant paragraph:
I also spent a lot of time thinking about SSRIs in particular, especially Irving Kirsch (and others’) claim that they barely outperform placebo. I wrote up some preliminary results in SSRIs: Much More Than You Wanted To Know, but got increasingly concerned that this didn’t really address the crux of the issue, especially after Cipriani et al (covertly) confirmed Kirsch’s results (see Cipriani On Antidepressants). My thoughts evolved a little further with SSRIs: An Update and some of my Survey Results On SSRIs. But my most recent update actually hasn’t got written up yet – see the PANDA trial results for a preview of what will basically be “SSRIs work very well on some form of mental distress which is kind of, but not exactly, depression and anxiety”.
What is the form of mental distress SSRIs work very well on?
I wasn't very impressed with David Burns' _Feeling Good_. I thought his suggestions were not particularly good and reading it felt like interacting with someone who didn't know me, didn't actually care whether my bad feelings were reasonable or not, and was just spouting out random reassurances in hopes something would catch hold with me.
On the other hand, reading Martin Seligman's Learned Optimism helped me quite a bit. Seligman actually seemed to understand the specifics of my negative thinking, and was persuasive in suggesting those extremes of negative thinking were both inaccurate and, with effort, changeable.
I know Burns is the big name in CBT books, but to me he's a puffball. I'd encourage you to at least pay attention and see how much Burns actually helps people who try him compared to other do it yourself CBT resources.
Plus the 'Feeling Good' book is a brick, overwhelming to anyone who is moderately to severely depressed. Burns' '10 Days to Self-Esteem' workbook is actually much better, I think, for 'classic' CBT, although I have to strongly encourage people to get past the insulting and misleading title.
"quitting a job (5.2 points happier)"
On a ten-point scale?
Jesus Christ.
Anyway, I feel like this would benefit from simpler language in some places. Attractor states are not common knowledge, and the word modality is hardly used by anyone.
Also, this quite a long chunk of text. Might benefit from being split into multiple pages or otherwise made less intimidating / time-consuming. It's already organized in a way that ought to make that easy.
I'd replace "10,000 lux light therapy" with the simpler version "bask in the sun with minimal clothes on"
I'd add a whole section on sleep hygiene.
Following this protocol was very helpful for me: http://tlc.ku.edu/elements
I found that Carlson's cod liver oil mixed with oatmeal worked well for me for both IBD and depression. It combines omega-3s with some vitamin D, essentially. Mixing oil with oatmeal slows down absorption of both the carbs and the fats.
Subclinical deficiencies of omega3s, vitamin D, Magnesium and Zinc are very common now.
The mod-med diet seems like it would prevent all that, but most people aren't on anything resembling the mod-med diet. Most people severely underestimate how horrible their diet is. Maybe a first line treatment should be a dietary audit.
Perhaps some discussion of things NOT to do, such as playing extremely intense video games like diablo 3 all day, causing prolonged elevation of cortisol levels that makes you physically ill + habituation to higher levels of dopamine which make you bored by normal productive activities. My first depressive episode may have been triggered by playing too much counterstrike deathmatch.
Speaking of what not to do, there are some interesting studies on excessive social media use making people depressed/anxious. A social media detox is another thing worth considering.
The 'basking in the sun with minimal clothes on' made me crack up! In most of Canada that is not an option for much of the year. Plus the sunlight is at an angle that reduces how helpful it is, from about mid-September to mid-April. Thank heavens for cheap therapy lights!
https://upload.wikimedia.org/wikipedia/commons/thumb/0/05/Bearded_seal_laying_on_ice.jpg/800px-Bearded_seal_laying_on_ice.jpg
If completely nude, it only takes a few minutes to get the full RDA of vitamin D at a UV index of 2. https://www.dailymail.co.uk/news/article-2004042/Naked-female-scientist-tries-tame-beluga-whales-arctic.html
https://vitamindwiki.com/dl2105?display
Cold therapy has additional benefits besides
https://www.healthline.com/health/cold-water-therapy#how-to-use
This is a great article, but I don’t really like any of the scenarios. All of them seem to be a mixture of ‘easy’ and ‘difficult’ at least in the way I would define ‘difficult’.
They seem to break down into 5 interventions that are cheap and easy to do, and then 3 others that are much more difficult.
I am not a doctor, but, if I was a patient, I would want to try all of the cheap and easy ones first, and only move on to the much more difficult ones if the cheap and easy ones don’t work— so, MY scenarios would be:
Scenario 1) Cheap and Easy— buy the four supplements recommended and the light therapy thing, and try just taking the supplements and turning on the light when you eat breakfast:
Big question on the cheap and easy interventions: is it OK to do this? to take all four supplements simultaneously? If it is, it seems like the easiest low energy low cost approach is to buy the light thing, and a bottle of each of the four supplements he recommends, and try doing the light therapy and taking all four of the supplements, at the dosage he recommends, as an experiment, for a month or two, until the supplements run out. If it helps a lot, you are done—buy more bottles of supplements, and, I guess, keep taking them, I guess, for 6 months or 2 years and then quit and see if the depression comes back. Although that is not 100% clear to me. Is the try it for 6 months/2 years recommendation specifically for the prescription meds only?
Taking all four supplements would be $2/day at the low dose, and $3.30/day at the high dose, see below. So, definitely, cheap and easy:
1) 15 mg of L Methylfolate daily. 120 capsules for $39. Works out to 32 cents a day. https://www.amazon.com/Opti-Folate-L-Methylfolate-Capsules-Optimized-Activated/dp/B07KPJ5PXS/
2) 100-300 mg of 5-HTTP. [start at 100 mg daily, then go up to 200 and finally 300 mg daily after a few weeks. ] $17 for 120 100mg tablets, so, 3 tablets a day, which works out to one bottle being a 40 days supply— works out to about 42 cents a day. https://www.amazon.com/NOW-Supplements-5-HTP-100-Capsules/dp/B0013OQI1W/
3) 1-2 pills a day of SAMe 400 https://www.amazon.com/Jarrow-Formulas-Promotes-Strength-Enteric-Coated/dp/B00V3M9CYY/ 43 dollars for 60 pills, so 72 cents a day for low dose, $1.44 a day for high dose.
4) 1-2 pills a day of fish oil https://www.amazon.com/Nordic-Naturals-Promotes-Optimal-Function/dp/B002CQU4Z6/ 57 cents a day for low dose, $1.14 a day for high dose.
5) the light thing, $114 one time cost. Very cheap and very easy to incorporate into your life— just set it up on the table and turn it on while you are eating breakfast.
Much Harder:
If supplements and light therapy don’t work, you have to go onto the much harder changes, which is, lifestyle interventions, or therapy, or seeing a doctor. Not sure which of the three is hardest, but all or any of them seem much more difficult than just taking some pills every morning, and using the light for a half an hour a day in the morning.
Scenario 2) Lifestyle Interventions
6) Never eat candy or sodas. But what about fruit juice? jam or jelly? baked goods? I’d guess he’d recommend avoiding all baked goods, candy and soda— but what about orange juice? is that just as bad a sugary rush as soda? is jam on toast at breakfast just as bad as a cookie?
7) cut back on all fats (except olive oil apparently—the diet he recommends recommends a ½ cup (3 ounces) of olives a day!!)
8) try whole grain instead of regular bread
9) Go for a 20 minute walk a day (in the morning ?)
Scenario 3) Do it yourself therapy:
10) Read this article and try the Behavioral Activation exercises https://medicine.umich.edu/sites/default/files/content/downloads/Behavioral-Activation-for-Depression.pdf
11) buy one of these books, read them, do the exercises, whatever they are. Feeling Good— (free on Libgen: http://library.lol/fiction/86D6D2057ED50F475957A7AE5EBEC7B6 )
or get one of them on Amazon: https://www.amazon.com/Feeling-Great-Revolutionary-Treatment-Depression/dp/168373288X/ref=sr_1_4?dchild=1&keywords=david+burns+depression&qid=1620632232&sr=8-4 or https://www.amazon.com/Feeling-Good-New-Mood-Therapy/dp/B07RB9DCG5/ref=sr_1_3?dchild=1&keywords=david+burns+depression&qid=1620632232&sr=8-3
Scenario 4) Go see a doctor:
12) make a doctors appointment and try to talk them into checking your thyroid, and try to get them to give you a prescription for either escitalopram or bupropion.
So, I'm not a doctor at all, I have no expertise in the subject at all. This is just the order I would try things in, simply based on difficulty. Eating right, and getting more exercise, and going and seeing the doctor, and reading books are all hard things--both to start doing, and to keep doing-- taking some pills and turning on a light is easy.
Really wonderful work.
I would call myself in remission from a lifetime cyclical clinical depression affliction. I am pretty open about that and so people ask me questions a lot. The first observation I always offer is that it is very important to me to keep front of mind, and took a long time for me to recognize, that depression is a formidable, agile disease which operates with a quasi-Darwinian imperative to survive and dominate me. For me the major go-to of my depression has and I suspect will always be this mantra: “your a piece of shit, you have always felt the way you feel right now, you always will feel the way you feel right now; it is pointless to fight this.” For me, the best antidote to this has been journaling and/or using a mood tracking app. Being able to point to something concrete and to say to my depression "bullshit, it says right here that May 25 was a terrific day and I felt good about myself” was and is a really powerful spell breaker. I would add those tools to your discussion.
I thought one of your most important observations was that depression fundamentally impairs and degrades the perception of reality. That has certainly been my experience I see some tension between that foundational fact and the reliance in reality perception that is implicit in accepting the afflicted’s view of what are "depressing jobs, depressing relationships, and . . . depressing grad school programs.” In the recovery world we would call emphasis on changing such external factors as pulling a geographic. My own experience is that relying on my perceptions while depressed is a pretty rocky road which includes big let downs when changing the perceived causative external factors does not in fact improve the internal landscape. External changes are, I am sure we would agree, no substitute for the work of tackling depression in the various way you lay out.
Consider adding even more cautionary statements around the topic of changing what isn't broken. When you find an exercise/diet/pharmacological solution that works (and I have thankfully) taking out the medicine piece is risky and needs to be done under very close supervision. My experience has been that these drugs have pretty long tails and half a dozen times over the last twenty tears I have lowered or eliminated doses, felt fine and then found myself re-shipwrecked on the rocks in a matter of weeks and genuinely befuddled as to how it happened.
I think of feeling like I and everything else are permanently bad as an attack of the bleaks. This at least gives me a little distance.
Just reading this and seeing how many potential treatments exist made me feel better. I took the beck depression inventory last night and scored a 20, but today I feel good without really doing anything different.
I was delighted to see how forthright you were on lifestyle changes, and especially love this piece,
" The most common are depressing jobs, depressing relationships, and (surprisingly often) depressing grad school programs. Their first priority should be to escape the situation. "
I would beg that you add "conventional middle school and high school" to the list of the "most common" for which the first priority is escape. My sample size is biased, but for decades I've created small, highly personalized schools with significantly greater autonomy than conventional schools (think of the range between Montessori to self-directed education and unschooling). Over those decades I've seen many dozens of students who had been diagnosed with clinical depression and/or anxiety, often suicidal, who escape school-as-they-have-known-it and, within a few weeks or months become happy and well, drop their meds, and wonder why they had ever been forced to go to a school that made them miserable all day every day. Often these families had already spent plenty of money on therapists, psychiatrists, treatment centers, etc. with no positive outcome.
At a minimum, mental health professionals should encourage suffering teens and their parents to consider alternatives to traditional schooling whenever possible.
While not explicitly related to depression, this Yale study is worth noticing,
"In a nationwide survey of 21,678 U.S. high school students, researchers from the Yale Center for Emotional Intelligence and the Yale Child Study Center found that nearly 75% of the students’ self-reported feelings related to school were negative."
https://news.yale.edu/2020/01/30/national-survey-students-feelings-about-high-school-are-mostly-negative
See also,
"► We document a large decrease in youth suicide in during summer. ► Adults from a slightly older age ranges exhibit no summer decrease in suicide. ► The summer decline in youth suicide is not explained by weather, unemployment, or SAD. ► The increase rate of youth suicide during non-summer months aligns with school calendar. ► That increase may be indicative of broader stress experienced by youth in school."
http://benjaminhansen.yolasite.com/resources/Back_to_school_Blues.pdf
See also,
https://flowidealism.medium.com/are-public-schools-causing-an-epidemic-of-mental-illness-1b37b6c0ef3e
https://flowidealism.medium.com/evolutionary-mismatch-as-a-causal-factor-in-adolescent-dysfunction-and-mental-illness-d235cc85584
https://flowidealism.medium.com/the-most-chilling-aspect-of-elizabeth-bertholets-thought-on-homeschooling-f135d837c
Some thoughts/suggestions:
1. I think that you may underestimate the biological effects of exercising. I agree that other factors are also important and might be even more important, but you are framing it in a way that sounds almost like "exercise is good but it is not really better than doing something else".
https://www.goodreads.com/book/show/721609.Spark is a decent book on this topic, with tons of references.
2. Maybe you could add more medication options. For example, MAO-B inhibitors such as Selegiline have a lot of benefits of MAO inhibitors without strict diet and other requirements. The downside is that it can start inhibiting MAO-A as well if you take too much and "too much" is different for different people.
Also, Pregabalin works well for some people and in my opinion, has a good risk profile. There
is some evidence that it makes you dumber meaning worse performance on a wide array of cognitive tasks but this effect is insignificant and probably reversible ("reversible" is a bit speculative though)
Also, I endorse Tianeptine. You might want to consider Amineptine as well. And if you are going to this "grey area" territory, Phenibut works spectacularly for some users. And baclofen is also pretty good.
Probably you know more than me about all these medications and already considered them and judged against them, but just in case something avoided your attention.
Oh Selegiline was mentioned and I somehow missed it, so disregard this part.
Scott already covered Phenibut in his article about gabapentinoids on SSC - it's a too problematic of a substance to just include it without a vast list of warnings, so no wonder it was not included here.
“Set yourself a regular sleep/wake schedule and stick to it. Choose a time of day and go on a 20 minute walk every day. Cut all soda, candy, and fried food out of your diet.”
- I think this should be included in all of the treatment protocols. At bare minimum certainly the last line
One additional thought SA. In the COVID suicide you wrote with your hallmark clarity that: "Okay, or it could be that there are two kinds of depression—the kind where you have some kind of stable predisposition to depression, and the kind where you’re upset because a hurricane just destroyed your city." This keyed me in to something that came out of a discussion of your treatise with my shrink -- in reality should it be split into two first-order sections -- depression as output/symptom and depression as input/disease?
- attractor states not really explained extensively enough to understand them if you don't know already understand what attractor states are
- typo: "Most studies that found supplementation helped got effects only from"
- disagree with your evaluation of mirtazapine, it's a great antidepressant. See my previous comment: https://astralcodexten.substack.com/p/oh-the-places-youll-go-when-trying#comment-1631108
- wouldn't RIMAs be the obvious (and underused) alternative to MAOIs? I understand they are basically second generation MAOIs, without death-by-cheese.
- physical illness/disability is a common cause of depression and a particularly nasty one, since you cannot "get away" from your broken body. Close to 100% of depression advice tells you to exercise, which you can't, and hearing that again and again makes you more depressed, to the point that seeking out advice for depression on the internet feels like twisting the knife and you start avoiding it. Adding a caveat, e.g. "exercise *if your health allows it*" would go a long way to soften the blow.
Is this supposed to targeted at scientists or at people who are depressed? The page starts with paragraphs upon paragraphs of technical details and taxonomy before anything manifests which would encourage a depressed reader to read on.
Maybe have some disclaimer at the top that this is for people who have a technical rather than personal interest in depression.
About psilocybin: It's illegal in the US and UK but not in the Netherlands and some parts of the Caribbean. There are fairly expensive psilocybin retreats in those places, but at least in the Netherlands you can also do a more basic trip-sitting arrangement. I wanted to try psilocybin for depression but was pretty risk-averse and didn't want to break the law or work out how to get a safe source of psilocybin. (The main danger in taking psilocybin is accidentally taking some other kind of mushroom that's not actually psilocybin.) I found a cheap flight to Amsterdam, bought some psilocybin in a shop, and stayed with an elderly hippie who trip-sat for me via a trip-sitting service I found online. It didn't make a noticeable difference to my depression, but it was an interesting and meaningful experience and was worth a try. I'd recommend that method to people who want to try psilocybin, don't know how to safely get it in their own country, and are particularly risk-averse.
About diagnosis: The only criteria I ever meet are low mood and thoughts of suicide. I think the DSM is just wrong about needing 4 symptoms in some cases, because even though I'm eating and sleeping fine, the whole "can't stop thinking about death" thing is a significant problem. To their credit, any provider I go to treats me for depression despite me not meeting DSM criteria.
About bupropion: another pro is that stimulates sex drive in some people, which might be welcome if your relationship has been suffering from depression and antidepressants.
Re iron supplements, you could mention getting one's ferritin levels checked after six months. It's rare, but too high a ferritin level (>200 ng/ml in women, 300 in men) can be a concern
Very thorough. One thing you hardly ever hear is: "By far the most powerful treatment for depression is GETTING AWAY FROM THE DEPRESSING THING." In my experience therapists never tell you this. It's beneath their dignity to tell you (for instance) that if you are frustrated at your job, probably you should just find a new job that's more rewarding and less frustrating. They didn't go to school for eight years to just give mundane advice! What they think they are good at is helping you make Herculean efforts to adjust to your cruddy situation rather than helping you make modest, constructive efforts to actually improve it. The problem is, the average person doesn't actually know that getting away from the depressing thing is really effective, and therapists are supposed to know this. (I would say it is depressing but that might get me into a bad attractor.) Another thing that lots of people don't know is that exercise is probably just one example of any kind of distracting and rewarding pastime, people think it is magically different from playing the piano or makings ships in bottles.
Re: the appropriate proportion of medical jargon for this sort of thing. I’m of the mind that the Scott’s of the world should use as much jargon as possible, just blow it out the top, and trust the audience to catch up. It shows respect for the intellect of the readership and is a realization that we’re all a Google away from a definition or scientific article. Once you start down the road of aiming for the least educated among a broad readership, you end up at the storied 8th grade level. This is different from a clinician tailoring his/her medical advice for a specific patient - in that case, the jargon should match the listener as best as possible.
I just noticed that I previously signed in to Comments as Scooby von Doo - I have no idea why I did that.
tl;dr:
The mathematical level needs mathematical notation and must not be ambiguous, because currently people like me who understand the larger point, won't read it carefully anyway [since it's just handwaving] and people who don't, need concrete structure or better yet links to where you explored all those ideas in depth before.
feedback on points 5 and 6:
"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 have offered 5 already, but...
the problem here is not that it's unfriendly towards people, who aren't deeply familiar with this kind of thinking.
The problem is, that it's so informal and sloppy, that people can't get to a deeper understanding from reading it carefully, even if they tried really hard.
consider how I read this:
At first, I just insta-read it and nodded "you're handwaiving at what I already read, thought about and liked". And you brought up "attractor state", "dynamical system", "inputs" on me, and I visualized a 3d graph.
Perhaps higher dimensionsional by adding colors, animation or vectors, if I really wanted to.
I think of "gradient descent", "slopes" and being trapped in a local maximium.
So I saw a "function graph", like this at 19:09:
https://youtu.be/IHZwWFHWa-w?t=1149
Or one like the ones in your "hills and basins"-metaphor:
https://astralcodexten.substack.com/p/ontology-of-psychiatric-conditions-34e
...
But then, I reread it after it was discussed in the comments and finally noticed:
you talk about "weight of the edges of the graph"!
Well, that can't be a function graph then, because you'd talk about slopes, not weights.
Weights are the little numbers over edges that connect vertices. Usually for cost or distance.
So we are doing weighted directed graph theory-style graphs.
Uhm... fair enough. Guess you could do that.
I don't even hate it, but then you don't define the vertices at all.
Implicitly perhaps in "either [life events or biochemical factors] or both of those can shift it into the new depressed attractor state".
I guess you mean V := {depression, life events, biochemical factors}?
And E = {(life events, depression, some_individual_number), ((biochemical factors, depression, some_other_individual_number)}.
"can shift into" makes no sense to me here.
Since a graph like that feels more static to me.
Well, I could mentally extend the graph into an automaton, petri-net or use a color-background to represent mood, but... I only came up with that idea, after I wrote the sentence two sentences ago.
Actually, you probably meant V = { depression, life_event_a, life_event_b, life_event_c,.... biochem_factor_a, biochem_factor_b, biochem_factor_c....}.
Okay, that graph is probably closer to what you meant.
But "either one or both" (and no concrete vertice-examples) really primed me to see that as three vertices, instead.
Which is why the graph theory graph interpretation was so implausibly poor, that it created a trapped prior of "function graph for dynamic system, makes sense, moving on" and blinded me to "edge of the weights".
Uhm... my reading process is mostly automated "scan for salient nouns and verbs and minimal connective structure, derive abstraction, if I understand it, skip to next parapragh".
"weighted edges" were suppressed as evidence, because it did not fit my assumption.
Same way, I wouldn't notice "Paris in the the springtime".
Hi Scott,
So the biggest issue with the article is its length. I didn't read it until now because I was intimidated by the length and I'm not depressed. (Though to be fair it turns out that the comments are the majority - the article is still a lot for a depressed person). That being said, it contains a lot of very good information and practical advice. I'd recommend putting each section under a text link, so people don't feel overwhelmed by the length and give up before they get to your advice.
I think the opening section 'The Short Version' contains too many long sentences with subsections and caveats. It doesn't feel comfortable to read or make me feel like I'm going to enjoy reading the rest of it. It seems written for a slate star audience and not your average depressed patient, or even my average patient (many of whom are slate star readers - thanks for the referrals).
I also disagree with your assessment of mirtazapine as a 'weak' antidepressant. I don't use it much because most people are put off by the risk of gaining weight, but I have been pleasantly surprised by its efficacy when I have prescribed it. I'm not sure it's less effective than SSRIs, and it has different side effect profile, so it is an important treatment option. I do think your description would put people off from trying it.
I am also surprised that you did not mention lamictal as a treatment option. While I do not usually prescribe lamictal as a primary antidepressant, it has been critical in the treatment of many depressed patients as an adjunct. I have effectively 'cured' at least 2 cases of chronic suicidality with lamictal+ therapy- I mean complete life transformation. It is also a great adjunct with stimulants for ADHD. If you are not prescribing this drug, you really need to be.
What about meditation / mindfulness?
Is photobiomodulation worth thinking about?
Also, if TMS were somehow available to a person would it make sense to do this before trying medications?
Excellent, complete, refreshingly open, candid overall! But the opening "big picture" or overview explaining "what is depression" could be improved. How? The overview as it stands begins by classifying depression as a "condition" - but a condition - of what ? It may be better to put "depression" in the context of normal mood variation, de-pathologizing low moods per se . "Depression" then would be an (abnormal, excessive, dysegulated, "stuck") low mood state - it's a condition of our "mood regulation system". Within normal ranges, we have low mood and elevated mood, anxious mood and calm mood ( putting moods as varying on two orthogonal axes, as behavioral biologists do when they theorize about animal moods - see Nettle and Bateson "The Evolutionary Origin of Mood and its Disorders" https://pubmed.ncbi.nlm.nih.gov/22975002/) and these moods are functional for us (and for many other animals) - they affect our interpretation of the world (the "priors", both in positive and negative directions) and reactions toward the world. One could add some evolutionary psychiatry thinking here on possible functions of (proportionate, normally responsive) depressed mood, and then, having put things in that context, say that (clinical ) depression is a condition where low mood gets excessive, "stuck", dysregulated, etc. I think this approach helps to reduce self-blame for feeling depressed even more than the "depression is a brain disorder" line of thinking.
Hey Scott, hopefully you have time to read this in the maelstrom of comments!
> "I once read an account by someone who said their mood was correlated with how many rooms they had been in that day."
I would really love to read this account. Could it be linked somewhere?
___
Also, since you asked for feedback, I tried to read this post when I was experiencing some milder depressive symptoms, and had to stop. I think this was an order issue. Personally, I felt having depression explained to me first was not very helpful.
My mood was very low, and the opening paragraph features, "Chronically depressed people live almost a decade less than non-depressed people", as well as a lot of information about how my brain wasn't working very well, which made me feel pretty powerless, and lowered my mood further!
I would maybe move the explanations of what is actually happening to the bottom, and start with stuff about diagnosis. That way people would probably be more likely to engage with the mechanics of depression when they're more capable of doing so.
Obviously this is just personal experience, it's possible that others would be comforted to know what is going on in the brain. (Although the chronic depression thing is definitely not comforting!)
Typos:
"If you have zero willpower, not enough enough to be the seed for a tiny investment,"
"If you do want to be hungry and sleepy, maybe because your symptoms include insomnia and loss of appetite, mirtazapine is great. " <-- I'd switch the order here for parallel syntax
"Regimen 3A: As 2A above" / Regiments 3B: could list out the full "person with high time/energy" for parallel syntax
I think the paragraphs explaining ECT wouldn't do a very good job of convincing someone who is afraid of ECT because of all the horror stories to change their mind. Even though I already have an overall positive opinion about ECT, after reading this I feel like I would be a bit less willing to undertake it. I think the praragraphs need a lot less mentioning of how scary the treatment and it's side effects are. Also the memory side effects are quite rare with modern devices and proper dosing/stimulus titration and generally a lot less severe than you write here.
Overall a great guide to depression treatment. Thank you!
A friend noted that some of the claims like "most people know if they are depressed or not" do not cite any data that back them up (and they did not resonate with her experience). IE, the claims should be either backed up by some evidence or marked more clearly as personal impressions. Especially since these things could (I guess) vary a lot and cause some depressed people to go "I don't know feel like I know that I am depressed, so I am probably not".
As an anecdote, at some point I remember thinking "I am DEFINITELY not depressed, or nowhere near it". And after I filled some depression score sheet, the result was something like "borderline between mild and moderate depression".
Question: When talking about MAOIs you didn't mention Moclobemide? I haven't had a depressive episode in over 10 years (better job, more money, exercise, keeping busy). However, in the past, I had depressive episodes and needless to say I have tried both a variety of medications and therapies. The best antidepressant I found for me was Moclobemide - it worked on depression without the worries of interactions common to other MAOIs. The next closest for me was Nortriptyline which nearly worked as well but left me knocked out the next day and affected work performance.
I really enjoyed reading the piece though. No comments that haven't been already addressed but would reiterate the paragraph writing about dynamic attractor.
I understand Moclobemide isn't licenced for use in the U.S. Do you know what the reason it is? And do you know enough to include it in your article for those of us who aren't based in the US?
Hopefully, I will never have another depressive episode but if I do and I get to a point of needing medication I know it will be Moclobemide I will be asking for.
Perhaps this is something only a layman would say, but I object to the sentence asserting that depression has been cured in rats. The whole concept of animal models of depression was a new one for me, and I'm not saying that it hasn't validity. However, I don't think it's fair to frankly speak of "depression in rats." To the psychiatrist, depression is a set of symptoms, most of which require a self-aware patient who can report them. I'm pretty sure diagnosis requires talking with the patient. To most non-psychiatrists, it is an ill-defined but definitely subjective experience. Either way, it's not something that can be ascribed to a non-sentient animal. Calling rats depressed implies that it can be diagnosed objectively, and it kind of implies that the pathophysiology is known, both of which are, to my knowledge, incorrect. Better than "cures depression reliably when we do it to rats" would be "has a positive effect in animal models of depression." A quibble, perhaps, but I think it's significant.
I saw a claim once that people did an explicit study of placebo effect in treating depression and found it to be effective. Like, not a blind study; "hi we're studying the effects of the non-functional pills with no medication in them that are used in psych experiments", so patients were specifically *told* they were taking a placebo...
Dear Scott, as always I'm deeply pleased by your writing style and by the ease with which you summarize such a vast and complex subject.
I would suggest adding a section on meditation / mindfulness practices, as this is a hot topic and patients constantly ask / wonder about scientific bases for it's efficacy.
As an extra I was wondering if you would ever consider writing a similar resource about High-Risk mental states / "prodromal" phases, since in my opinion there is lots of information but not a lot of well-distilled knowledge surrounding the subject.