> Ray’s mother asked the Lodge to give him antidepressants. But to the Lodge psychiatrists the premise of this form of treatment – to be cured without insight into what had gone wrong – seemed superficial and cheap. Drugs “might bring about some symptomatic relief”, Ross, Ray’s psychiatrist, acknowledged, “but it isn’t going to be anything solid in which he can say, ‘Hey, I’m a better man. I can tolerate feelings.’”
I remember a HN comment from trained pharmacist (https://news.ycombinator.com/item?id=32103546) that argues the same thing: “I promise you that no drug that you can take can make any permanent changes to edit your mind”
Ray looked at two different stories about his illness, the psychoanalytic and the neurobiological, but both "failed him". I would say that the psychoanalytic story has a better chance of explaining his case, but for some reason he wasn't receptive to it.
Relatedly, the chemical imbalance theory of depression was disproved in a popular study published two months ago. Here is a good summary: https://youtu.be/TZhgvr2rbwE. But SSRI are still effective, at least in reducing symptoms. We basically don't understand why and how they work.
While what they're saying is true, to me it rings just as misguided as not taking pain medicine when you have a broken leg until it has properly set first.
Medication for neurological issues isn't and shouldn't be the end-all-be-all but can indeed be a way to manage the issues at hand while teaching the tools needed to deal with the symptoms via therapy if possible.
Taking pain killers can exacerbate injuries by masking the pain caused by behaviours that cause additional trauma.
I've seen a child's broken arm go from a scheduled intervention to an emergency surgery because the xray techs manipulated it poorly. The kid felt nothing thanks to the opioids she was given, and so didn't protest when they made a further mess of it.
Maybe you're depressed because your life and environment is actually shit and you don't know how to fix it. Maybe taking happy pills just eliminates the only signal telling you to take your hand off the hot stove.
I don't think depression is like that. Depression is not being sad but rather just blank and those are not happy pills, those are feel a bit something again pills. Which enabled you to take the hand of the stove albeit imperfectly.
Is that really how it is for you? The blank days in my opinion are the good ones, the level and balanced ones where I can just be in the zone or frankly even just zoned out.
The depressing days are the ones where my brain decides to sample from its wine cellar of my past mistakes without my permission.
I'm not really depressed or I don't think I am, although many things in accounts of depressed or formerly depressed people resonate with me.
I'm basing my understanding of what depression is on accounts of people who were depressed and got their meds. They always mention starting to actually feel some emotion. Like in case of this patient it was sadness about his children that made him cry for the first time after many years of just thinking how sad it was. Another case that ifluenced my tinking was illustrated accout by Hyperbole and half. After she got her meds she initially started to feel anger then joy then sadness in sort of explosive manner. As opposed to before the meds when she was feeling just empty and wanting to not exist.
The belief that underlying cause is not events or thoughts but physical damage to nervous system comes for me from experiments with ketamine I read about, where in vivo it shows to grant very rapid improvement in depression symptoms and in vitro it literally makes neurons grow new dendrites (or similar structures).
As for me personally I recently experienced a loss of a loved one and my life is very empty right now. So I'm thinking about it a lot and I have some of the coping mechanism the patient from this article invented. Like for example I started walking a lot this year and thinking about a lot not so great things when doing that. I walked to the point I injured my feet from the sheer amount of walking. Ball of my right foot still hurts after two months since I quit. But I still can cry or laugh or be excited about stuff and while some aspects that were never my strong suit like keeping my living environment orderly are now very inadequate I managed to function for 3 years with my sadness gradually lessening.
This belief that depressive thought have physical reason I think is helping me a lot. It makes easier to disassociate from their content.
I can just gloss over their content with statement that of course I'm making up bad stories and interpretations because I'm in a bad mood caused by bad physical condition. Once I improve it by eating, sleeping and all that I'll think more reasonable thoughts.
> misguided as not taking pain medicine when you have a broken leg until it has properly set first.
I'm arguing that pain killers are a calculated risk, and can lead to further trauma, even in situations of broken limbs. It's not misguided to forgo them entirely, if you can.
More broadly to the greater discussion: treating mental illness as a chemical imbalance risks further trauma because it risks masking the symptoms without treating the cause. It can be appropriate, but should not be taken in isolation as a potential cure or sole treatment.
> to me it rings just as misguided as not taking pain medicine when you have a broken leg
This is a bad analogy in so many ways. Most pain medications are short-acting, so one knows pretty quickly whether they work. People prescribed antidepressants are told to wait weeks to see positive results, and a large percentage of them won’t actually see any-and even those who do see positive results, it is often unclear if the improvement is actually due to the medication, or due to something else instead (therapy, lifestyle changes, self-limiting disease course, etc).
If someone out there is taking antidepressants, and they feel it works for them-great. But having tried a range of antidepressants over the years (SSRIs, MAOIs, SNRIs), I’ve reached the conclusion that for me, they are pointless-I’ve never got any benefit from any of them. Some people will swear that they’ve saved their life - I see no reason to argue with that, it could well be true - but I’m sure there are many other people out there just like me. It’s a game of chance, and deciding not to play (or to stop playing) can be a rational and informed decision (at least for some people in some circumstances.)
To stop playing that game of chance can certainly be a rational and informed decision. If you've tried multiple drugs of multiple categories and none of them work, chances are good that the next one won't work either.
But not even trying? I don't think that's a rational and informed decision. Sure, it might take two weeks, and sure, there are side effects, but if it works, it'll greatly improve your condition. If your condition is serious, taking a pill every day and waiting for two weeks isn't a huge investment.
It's like betting at roulette, you don't have to pay to bet $10000, but you'll get the full win if you're lucky. And you have to wait two weeks after each bet to know whether you won.
> But not even trying? I don't think that's a rational and informed decision.
My GP told me that for mild to cases of mild to moderate depression, he’s hesitant about introducing antidepressants-be said they can worsen concentration at work, impairing performance, thereby introducing additional life stressors, leading to more depression not less. A person seeking antidepressants who was dissuaded from doing so by that advice is arguably making a much more informed choice than if he’d just given them what they wanted from the start.
Of course, there comes a degree of severity (drawing that line is sometimes a subjective judgement call) when he doesn’t have these qualms any more.
Although (this is my view, don’t know whether he agrees), if one’s situation is severe enough to warrant trying antidepressants, they might not be enough. While I’m no great fan of antipsychotics, if I was in a real crisis situation, I’d much rather something that delivers noticeable results right away, than something which might take 2-4 weeks to do nothing.
I do agree with what you're saying about severity. For something like seasonal affection disorder or a moderate depression, you'll probably not want to reach for SSRIs etc as the first cause of action, much like a gastric bypass isn't the right tool for someone who is slightly overweight. But it is a good tool to have for severe cases, and the idea of "it's not real weightloss if you didn't achieve it through power of will alone" is damaging.
how long were you on each? It takes a while for any changes to surface (several weeks to months).
that's not the case for benzos, which have an immediate effect, but those should never be taken over a longer period.
I have read an interesting thought the other day about the side effects of those drugs from a psychoanalytic poit of view. It's just a psychoanalyst's thought, nothing scientific:
“Recently the thought occurred to me that we have antidepressants back-to-front, as it were. The listed side-effects of these drugs (mostly SSRI’s) is really the main action, and the advertised effect is the real side effect.
In other words antidepressants reduce anxiety and depression as a side effect of reducing libido – in the more inclusive sense of ‘life force’. Perhaps the relief of depression occurs because anxiety and depression are symptoms of libido or life energy hitting up against an obstacle or difficulty either in the internal or external world. This obstruction interferes with the ability of libido to express itself.
Reduce libido and the unpleasant effects (depression and anxiety) of libido encountering an “obstruction” are correspondingly also reduced.”
That doesn't really match my experience of depression unless you somehow redefine all those terms to mean something else.
It's hard to see where the libido is in someone who doesn't want to get out of bed, even to eat. Or in the case from the article, someone who feels like a piece of wood, and who paces the hospital like a Roomba.
All effects of drugs are effects and they become side effects when they are undesirable. You used to be able to buy the same medication as either a decongestant and an appetite suppressant. In either case, the other effect is a side effect.
On the other hand, if you took an antacid every day for your depression, and had no effect on it, for years, you might consider that it didn't work. However, the analysts didn't think that was possible to say about analysis.
Thank you for sharing this. Psychoanalysis is often heavily criticized but it has this nice tendency to be curious and open about things and produce intriguing and interesting thoughts
It's weird that we treat psychoactive drugs differently than other drugs. We don't have a fear of a diabetic becoming dependent on insulin or someone with high blood pressure becoming addicted to beta blockers. There are side effects is a bad generalization of all drugs used to treat mental health issues. When I say I am taking beta blockers, most people comment on how I am a bit young to be taking them, but when I was prescribed benzos for the same condition, everyone decided to become my doctor and tell me what I should and shouldn't take. Endless stories about how then knew someone who got addicted to pain killers and became homeless and how they heard benzos are just as bad. I chose to switch off benzos to beta blockers.
Doctors and the patient are the best judge for the benefits and risks of living with certain conditions vs being medicated for them. In most cases there aren't side effects.
"It's weird that we treat psychoactive drugs differently than other drugs. We don't have a fear of a diabetic becoming dependent on insulin or someone with high blood pressure becoming addicted to beta blockers."
It not that weird. The brain is the most complicated organ in the human body. Science understands how the kidneys work but largely doesn't understand how the brain works.
If you think these drugs are worth trying, I think you should make the argument without these sorts of analogies.
"Doctors and the patient are the best judge for the benefits and risks of living with certain conditions vs being medicated for them."
Okay, but if you were to follow this advise you should scold anyone who says "People with mental health problems should take drugs..." That's for the doctor and patient to decide, right? But you only scolded the person pushing back at this statement.
I do. I equally scold anyone that says MDMA or LSD is the cure all of depression.
It's not an analogy. There is no mechanical difference between someone using Amphetamines to treat their ADHD and someone using insulin to treat their diabetes. There are just as many external as internal factors that go into how someone can get diabetes and what dosage of insulin they need at a specific moment in time. Science has advanced to a point where diabetes specifically can be monitored easily by a patient. The same is true of hypertension.
The difference for mental health issues is that there is no easy quantifiable way to diagnose someone.
Every organ is the most complicated organ in the human body, at a certain level every organ has a mechanism science doesn't understand yet. That's not a valid argument.
The same is true for pain management. And Multiple Sclerosis.
I would suggest you look into the modern state of neurophysiology and neuropsychopharmacology. The "we don't understand" is not true anymore. The reality is that there are so many factors affecting a certain visible outcome that it's hard to specify a root cause.
I am not a medical professional, I have only taken some 300 and 400/grad level courses in psychology.
Because the kidneys are much more simple than the brain, diabetes is diagnosed with a blood sugar test.
In contrast, mental health diseases are generally diagnosed by talking to the patient, because there is little understanding of the underlying biology.
"I am not a medical professional, I have only taken some 300 and 400/grad level courses in psychology."
Do you believe your professors would agree that the mechanism of treating ADHD is the same as treating diabetes, or that the kidney is as complicated as the brain?
"I would suggest you look into the modern state of neurophysiology and neuropsychopharmacology. The "we don't understand" is not true anymore. "
Last time I "looked into it" did not result in a belief that we understand the brain.
I just "looked into it" for a minute or two, and here's an interesting APA article from 2012 where a professor of brain science and Nobel prize laureate is stated to believe the field is where cardiology was 100 years ago. I recommend reading it:
This is where the problem is and what I argued above as well. People handwave the efficacy and use of medication by arguing "we don't understand". That is exactly what you are doing. A lot of my knowledge comes from when I was able to work with surgeons at the local university hospital in order to do signal processing on data collected from electrodes that were installed into patients who suffer from Parkinson's, for DBS.
I would urge you to look into the recent advances in neuroimaging.
The reality is the news tools for research are still in their infancy. It's not close to the maturity that the diagnosis of diabetes and other diseases are at. But there is a very clear path forward, it's no longer theoretical.
There is still no clinical definition of insulin resistance.
And as far as ADHD and Diabetes go, yes I can confidently say the current medications and therapies that are available for Adhd can address most cases similar to how insulin does for diabetes. Treating metabolic disorders is as complex as treating ADHD. Stimulants don't "fix" ADHD any more than insulin does for diabetes.
The complication doesn't come from the lack of science, it comes from the fact that behavior and cognition is affected directly by the stimulus people are exposed to. I can't play music that will distract a kidney but I can distract a child very easily the same way.
I did read the article you listed,
"In McNally's view, there's little danger that mental health professionals will forget the importance of environmental factors to the development of mental illness. "I think what's happening is not a battle between biological and non-biological approaches, but an increasingly nuanced and sophisticated appreciation for the multiple perspectives that can illuminate the etiology of these conditions," he says.
Still, translating that nuanced view to improvements in diagnosis and treatment will take time. Despite decades of research on the causes and treatments of mental illness, patients are still suffering. "Suicide rates haven't come down. The rate of prevalence for many of these disorders, if anything, has gone up, not down. That tells you that whatever we've been doing is probably not adequate," Insel says."
He argued exactly what I am still arguing. Specific to how far out he thought these tools of diagnosis were, I would absolutely disagree. Having a Nobel prize doesn't mean his predictions are prophetic.
It's not just the field of neuroscience, the last 10 years of technology have reshaped the entire landscape of medical diagnosis and treatment. If I said that AI will be able to help diagnose cancer in the next 10 years in 2012, most people would think I was being optimistic to a fault, but that's where we are now. The fMRI was invented in 1991.
From APA, if you clicked on neuropsychology and scrolled down, you would have seen Michael Treadway’s fantastic work at Emory on the relationship between inflammation and stress and how it links to depression.
"“What I’m seeing with my research, and that of others, is that there are many types of depression, schizophrenia, or any number of mental illnesses, each with its own source,” Treadway said. “I would really like to get to the point where we have discrete definable pathologies that are measurable, using objective tests, for different types of depression, for example, or even different symptoms of depression. That could really open up a world of new treatment possibilities.” "
I can only hope you gain some of my enthusiasm after reading some of these.
I don't think you can decouple mental health from politics and economics. Poverty is a huge stressor, especially when combined with homelessness. So to quantify suicides accurately you'd have to exclude the effects of the relatively benign 90s with the current outbreak of extreme financial stress.
I agree with your last point though. Mental illness is the result of a complex mix of social/personal, political, and financial stressors, biochemical weaknesses, and unhelpful cognitive habits. But current diagnoses are behavioural, not contextual. And treatments tend to concentrate on one factor to the exclusion of others.
Having said that, I think "you'll feel better with insights" line of psychoanalysis continues to be bullshit. Analysis has a terrible record of delivering useful results, and "insight" usually means "learning the mental model the therapist uses without questioning it."
There are better and more effective cognitive and psychotherapeutic techniques which work more quickly and are cheaper. Combining them with chemical and welfare help shouldn't be an issue.
"Treating metabolic disorders is as complex as treating ADHD."
This sentence presumes ADHD is a medical discovery, not a social construct, and several other things other things which are debatable.
(This is not to discount the suffering of anyone being treated by a psychiatrist, suffering is real, diagnostic criteria, the objective reality of mental health categories, and what percentage of people benefit from drugs is debatable).
"the last 10 years of technology have reshaped the entire landscape of medical diagnosis and treatment."
I care about whether people are healthier than they are 10 years ago, not how exciting it is to read an article with the words "cancer" juxtaposed with "A.I."
This quote suggests people aren't getting any healthier, which suggests your claims about the wonderous advances over the last 10 year may be overblown:
"Suicide rates haven't come down. The rate of prevalence for many of these disorders, if anything, has gone up, not down. That tells you that whatever we've been doing is probably not adequate,"
The validity of psychiatric diagnoses is far more debatable than the validity of a (non-psychiatric) medical diagnosis such as type 1 diabetes mellitus. The later is - at least to a certain degree - a natural category - it is very open to question whether any of the former are. I can’t agree with drawing some parallel between diabetes and ADHD while ignoring this “elephant in the room”
No, that’s blatantly untrue. The liver is one of the simpler ones as it’s all single cells, and the brain is definitely the most complex. I’ve never heard anyone say they are equally complex.
That doesn’t mean we understand everything about the liver, but we are hell of a lot closer than the brain.
The liver itself might be simple but the complexity is in the enzyme pathways. The marker of "elevated liver enzymes" doesn't tell us much.
Taking a step back, there is only one organ I will admit we understand better than the brain, the heart. It's the only organ where we know enough to replace it with a mechanical counterpart. We don't know enough to make it last a long time, but it's enough to prolong someone's life in a meaningful way.
> The "we don't understand" is not true anymore. The reality is that there are so many factors affecting a certain visible outcome that it's hard to specify a root cause.
That sounds like "we don't understand" except now we slightly better understand how little we understand. We don't even know how Tylenol works.
Diabetes can sometimes be treated with methods other than insulin [0]. I think that these dietary treatments are always a better option than insulin.
The same way with high blood pressure. High blood pressure should always be managed by "diet and exercise" before meds are brought in.
All of these drugs (diabetes drugs, high blood pressure drugs, heart medication) that are regularly being used to treat lifestyle diseases should be seen as a last resort with the main goal being to help people get to a point where they don't need them.
... until you hit 55-60 and irreversible changes to your body's hormonal system mean diet and exercise alone cannot control your hypertension, or late onset diabetes.
I mean sure. Try. I had 10 years on Hypertension meds, 15 off, and I am back on despite significant weightless and increased physical activity. Idiopathic can happen.
Psychiatric treatment is not without its dangers either. A bad psychiatrist can fuck you up. I know several people that experienced this. I also know a couple of people who were messed up by poorly prescribed psychopharmaceuticals. The ugly truth is, there's no safe solution.
I would place antidepressants under a different umbrella - closer to insulin or other chronically required "maintenance" medicine required to sustain life.
Anti-depressants don't take pain away. In some cases, they make it possible to even feel pain.
I'm ~6 years into my therapy journey at this point and I'm not on antidepressants at the moment, but I have been in the past when I needed them.
I'm fortunate that I was able to stop, and that was partly because I put my work life on hold to go on sabbatical and use all of my capacity on myself for awhile. But that doesn't mean everyone can or should.
I think it's also worth noting that especially now, mental health issues are increasingly caused by advancements in technology we don't yet know how to cope with, and from which there's very little escape.
Meds allow one to do the hard internal work that would be significantly harder to achieve if they don't have the capacity to keep a well functioning life up and running.
I think only embracing one or the other exclusively is where things start to go wrong, and what I took from the article.
Studies to show morphine is better than placebo in treating what?
Here is a link for Study protocol for a randomised, placebo-controlled, single-blind phase II study of the efficacy of morphine for dyspnoea in patients with interstitial lung disease (JORTC-PAL 15) https://bmjopen.bmj.com/content/11/5/e043156 .
I would suggest you look into the drug approval process in the US, I think you will learn a lot.
As a trained pharmacist, the previous pharmacist is wrong in their interpretation and in their explanation. Specifically the way they explain the duration and mechanisms of the drugs is incorrect. While the main focus of discussion tends to center around the “serotonin” aspect of SSRIs, this is akin to discussing a road trip and only talking about turning the ignition before you leave the drive way. Serotonin receptors in the prefrontal cortex are the beginning of the signaling pathways that are to a greater extent controlled by glutamate, nmda receptors, and GABA. Not to be forgotten are also the dopamine and epi/norepi. All of which are affected downstream from the initial signaling of 5ht1a/b and 5ht2a receptors. Changes in concentrations of these neurotransmitters, their receptors, and reuptake vesicles, lead to system level changes in mood and behavior. The idea that some “small changes” in serotonin levels for a few weeks is all that occurs with an SSRI is just plain incorrect. The resulting fluctuations from baseline in neurotransmitters and receptors translate to slow changes in plasticity and “direction” as pathways are reshaped. Depression stems from a “negative cognitive bias” that deepens and is self-reinforcing over time. Changing that bias by reshaping pathways takes time. For some people, a very long time, and for others (arguably most) the drugs alone cannot accomplish this change in direction toward s more positive cognitive bias without cognitive behavioral therapy, rebuilding social support systems, and a change of environment. It’s true that everyone has different chemical concentrations, different levels of enzymes for breaking down neurotransmitters, and differences in receptor availability and that has been reduced to an idea of “chemical imbalance” which is not only too simplistic but also it treats a person like a baking recipe that would be turn out well with just more baking powder. That PharmD in the comment did the same kind of reduction here. At a molecular level, permanent changes absolutely can and do happen. That is essentially what the mechanisms at work in ketamine therapy have demonstrated providing strong evidence for thr neuro plastic theory of depression.
Drugs can give you the insight to change your perspective though. From my understanding, depression is a deadly spiral of mental state leading to chemical imbalance which further reinforces the mental state, making it impossible to see outside that worldview. Thus drugs can take you out of that cycle and give a glimpse outside, and then even after the drug wears off the change in perspective is persistent.
> From my understanding, depression is a deadly spiral of mental state leading to chemical imbalance
There has never been any good scientific evidence that depression (or any other mental health issue for that matter) involves a “chemical imbalance”. It is, at the very best, a debatable and unproven hypothesis - yet many think it is some proven fact. To pick out just a couple of the numerous sources which confirm this, see https://www.nature.com/articles/s41380-022-01661-0 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1277931/
> There has never been any good scientific evidence that depression (or any other mental health issue for that matter) involves a “chemical imbalance”.
Transfem here. Gender Dysphoria is a hell of a condition and it usually improves massively as soon as people start taking cross-sex hormonal replacement therapy (HRT).
In my personal experience, it was almost like magic how quickly and how much I improved when my testosterone finally fell to zero.
You’ve wanted something for years and now at last you are getting it - that fact alone has to make a person feel happier and feel like the trajectory of their life is turning in a more positive direction. It is near impossible to determine what consequences of cross-sex HRT are due to its direct biochemical effects, and which are due to those kinds of psychological factors.
I take SSRIs for anxiety and feel like the opportunity cost of trying to survive without them is too great. The good things in my life would be too disrupted by the extra load of tolerating those feelings. And those good things are protective against anxiety.
I have faced the opposite problem in India - psychiatrists insisting that they won't treat me without pills and even disparaging therapy as it "takes a long time and 'unreasonable' commitment from both patient and doctor"!
True, a patient's ignorance or belief system can be an issue. There's also two other factors - (1) some doctors often don't update themselves on the medical advances in their field and (2) doctors who treat mental health problems are also the most suspicious about trusting what their patients say (which is somewhat understandable when you consider the kind of mental health issues there are where patients do lie or can be delusional and all that isn't easy to ascertain in one or two sitting). So dealing with new therapists is always a pain as they want to do their own evaluations and insist on medicating you even if you don't need it. More so when you can't find therapists well versed with newer therapies like CT, DBT.
> “I promise you that no drug that you can take can make any permanent changes to edit your mind”
I don't agree. I know a couple people with mental illness that seems to be due to runaway "feedback loops". Drugs seem to reduce the "gain" on those loops and enable them to actually live life.
Besides, most research I have seen seems to indicate that the people who get appropriate amounts of both medication and therapy seem to have the best outcomes.
Worth noting that understanding why a problem occurs is not the same as treating that underlying condition. And moreover, you can treat and even cute something without fully understanding the precise mechanics of its attack vector, per say.
First, I fully support the use of drugs, and I've been on antidepressants. I've also had surgeries, and have had the "good stuff" on a few occasions. Drugs are a necessary part of modern healthcare.
> People are pointlessly scared of drugs ... I exercise zero willpower to avoid them
People are appropriately scared of drugs. You are very fortunate to have that willpower.
I exercise no willpower when I think about the bottles of Bourbon and Scotch in my liquor cabinet.
Our anecdotes don't change the reality of addiction. We're lucky.
But that's the point. I have no willpower. I just don't need it for opiates. And it's quite clear that the effect varies for people. Some people experience addiction and others don't.
I'm glad the present system doesn't have holier than thou doctors sitting around lecturing you while your vision whites out in pain. And you know what? I'm glad that there are medical staff out there intelligent enough to be aware of this for physical pain.
The mental guys haven't quite figured it out yet - mostly because their studies don't replicate so they have very little knowledge.
Well, clearly the 3% of people who get addicted on exposure should sit it out and just live in pain but for me that helped me recover quickly.
Fortunately for me, my doctors and nurses weren't obsessive ideologues and worked with me on a pain management program that involved opiates.
Can you imagine having to sit in that bloody bed unable to move unless you hit the button to call the nurse all while in mind blowing pain? I'll pass! You can keep your sanctimonious doctors giving you lectures. I'll keep my professionals. Big ups for the folks at Zuck SF Gen.
> In a draft of his memoir, Ray modified his definition of depression: “This is not an illness, it is not a sickness – it is a state of disconnection.”
I've seen it in myself and in some of my closest friends, where we just start to disconnect more and more from others, more and more from ourselves. Especially from how we're feeling. Wanting to avoid emotions and thoughts, suppress them, repress them. I'm not too familiar with the vast theory in psychology and psychoanalysis, maybe what I'm proposing is quite aligned with Freudian or other thinking.
Just seems to me that when we disconnect, especially from how we're feeling, we can slowly start to shrink into ourselves and if we don't stop it, we sometimes implode.
Conversely, that by connecting more with how we're feeling, we can start to expand a bit, not just with ourselves but with other people.
One of the challenges in that being as we expand, things happen that can make us want to contract (rejection, being ignored, idolized, etc) and then back on the shrinking path again.
'Feeling nothing' I don't believe is a thing, rather the failure to know what you feel means you have isolated your consciousness from awareness of how you actually feel. That's a sign of the disconnection you are talking about.
Connecting with others is hugely important, but also a hard step. Exercise can help, and can be seen as connecting with yourself. Don't attack yourself for failing to meet any particular exercise target, though.
The question is, what is it about these challenges that cause you personally to retreat into depression, because we know that there are people who can tolerate some amount of rejection. I think that’s a psychoanalytic question, to explore what it is about you personally that responds with depression.
Talking about mental health is extremely challenging. On one extreme there is stupid: the people who believe none of this science is a form of health, or even real. On the other hand there is the disabled: the people who likely have undiagnosed mental health disorders themselves and are incapable of processing any of these conversations.
Such failures to process these vital concerns touch wide reaching aspects of discourse from politics to work to culture generally and that is quite a problem.
A key issue is also that even within mental health services there is animosity towards psychiatry.
Whatever one thinks of antidepressants or antipsychotics (maybe less mood stabilizers I think), psychologists hate them. And I think while psychiatrists see psychology as helpful for their patients, psychologists can see the use of medications as a failure.
I could say more but I think I'll just leave it at that.
I would appreciate it if you did say more. I don't understand how you came to the conclusion that psychologists hate medicine. In most cases psychologist and psychiatrist work together to provide treatment to a patient. Why would psychologists see the use of medicine as failure?
Psychiatrists prescribe medications and psychologists perform counseling. The role of prescriptive medication is to modify behavior that either increases focus or stabilizes emotionally heterogeneous states. That medication is often issued in consultation between a psychiatrist and the treating psychologist to enhance receptivity to counseling (or other social contexts) otherwise it may interfere.
There are few psychologists who deride medication just because they can’t prescribe it. In fact, it’s largely the other way around - psychiatrists look down upon psychologists and often decide their work.
It would depend where the participants work, but I'd love to see an attitudes survey.
It's be tricky as people are unlikely to be entirely honest giving opinions on colleagues.
I linked to a survey of therapists on medication and the highlights of my OP were reflected there.
Some therapists do not trust medications, see them as harmful, overused or subverting therapy.
But therapists are not necessarily clinical psychologists.
And in the UK at least every training psychiatrists would have practiced at least two modalities of psychotherapy. That's mandated by the GMC (General medical council which regulates medical licenses). Usually one cognitive therapy and one psychodynamic therapy.
I've seen research which shows that those that conduct it feel that it's beneficial and effective.
Psychologists encourage patients to seek out psychiatrists if they believe medication is likely to help a patient. Psychiatrists aren't the same as pharmacists, they are an active part of your treatment plan. I would suggest you take some time to understand the end goal of treatment and why people seek treatment. The goal is not to make patients docile.
> In addition, the qualitative aspect of therapist views showed that, perhaps above and beyond this, therapists feel the impact of psychiatric drugs on the therapeutic relationship. While some felt that drugs could improve client engagement, there was a strong feeling that their effects (and side effects) had a negative impact on clients' ability to work therapeutically.
> Having to take meds can be viewed as failure by some therapists which is not helpful to clients. (Respondent 906)
One of the therapists even calls out other therapists about seeing medication and failure.
Probably better to read the whole thing but boils down to psychologists don't like medications.
gonna do a stream of consciousness as it's late here, the topic is pretty overdone and constantly attracts hate and honestly this is opening a can of worms but effectively you will see many many psychiatrists and doctors in general refer patients to psychological intervention. Psychologists recommending someone seek medications is nearly nonexistent.
Why? I suspect its similar to the divide between doctors and midwives. Midwives can occasionally see caesarian sections as 'cheating' and labour a right of passage for women.
Psychologists do something very similar, psychotherapy is a protracted unpleasant affair something that is worn as a badge of honour by those that undertake it.
Then someone takes a pill and says well to be honest I won't bother.
That irks some.
But more to the point, there are also audits and overall several pushes to reduce usage of psychotropics [0]. So it can literally feel like a failure as a psychologist if one of your patients has to start taking a medication and later in the week you literally have to track that a failure.
[1] is a recent interview in BPS (British psychological society) about a psychologists who started an organisation for evidence based psychiatry. CEP receive funding from Scientology.
The most prominent UK psychology society promoting a piece about an cult funded body that opposes medicines.
If you spend any time looking you will find psychology is rife with anti-psychiatry. This is just the article from the past few months that came to mind.
I wish there were more long-form articles like this, that explored the way this debate unfolds in the literature, and rigorously presents the arguments of each side. The article invites readers to make up their minds on psychiatry (drugs) vs psychoanalysis, but through narrative rather tha logical arguments. Would make for a great movie, but it's hard to derive anything from this.
It's clear that the neurobiological approach focuses on correlates rather than root causes. Brain chemicals are no more the "sources" of emotions, than emotions being the source of neurochemicals. And psychoanalysis tries to weave narratives that explain behavior, but those narratives may or may not produce any insights.
Surely there's smart people who can see the basic flaws of both current approaches, and are trying to build more rigorous models of the mind's functioning?
I am currently taking depression medication. Have been taking it for the last five years. It may or may not be helping me. I did try to taper it off with help from a doctor, but I literally became crazed from withdrawal. I went back to the same dosage as before.
At this point, I’m afraid I’m stuck with the medication and I’ll have no way of getting off it. Who knows what it is doing to my brain chemistry?
I have some thoughts about this, but I'm afraid the nuance won't translate well.
If a person's situation is causing harm or trauma, fix that first.
I understand the brain as a set of modules with soft wiring when you are born. There are tendencies, but no well worn pathways. In people with profound mental health issues, those modules and wires are fundamentally damaged in some way.
For other people, the pathways they build between modules may be damaged by trauma. Some modules may be miscalibrated.
In either case, medication may help a person feel and perform better.
In either case, therapy may help a person to understand themselves and to modify cognitive behaviors. To break loops. To understand sensations and emotions. To connect with other people.
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An analogy - if you sprain an ankle, you may take medication for the inflammation, and you may also go to a physical therapist to build back muscle and functionality etc.
Don't take the analogy too far - I'm only saying that layered treatment can be much more effective than a single solution.
Psychoanalysis is criminally underrated in the US. It’s detractors broadly don’t understand it. It has the potential to seriously help tons of people, but it is understandably challenged, as it represents a painful reckoning with yourself.
Who would want to find out that their personality causes many of their problems? Maybe it requires a bit of masochism to take advantage of.
I really don’t think this is the thing that puts people off.
I think the main factor is financial cost. psychiatry is extremely expensive, and often hard to get hold of. another large part is the representation of psychiatry in films, where it’s often depicted as mimsy-whimsy dream interpretation with freudian psychobabble. thirdly I think some people assume that there is only so much people can do with words, and/or are afraid of medicine that influences the brain
I agree that it is not the only thing that puts people off. The cost is a significant challenge.
But I think it is one of the biggest factors. You even display some of it yourself in the way you refer to dream analysis and Freud. It’s not just you, psychoanalysts themselves have anxieties about delving into the uncertain, unproven speculative parts of their minds.
The hatable thing about psychoanalysis is that it often suggests that we cause our own suffering. I’m repeating myself, but I don’t think that’s a welcome message for basically anyone (and obviously, it is not true in many cases). And that kind of explanation can be oppressive, when misused.
Every single person I know on any sort of mental health medication also had therapy before and after being prescribed it. Therapy does help, especially when your illness requires you to learn how to cope with your condition (and the fact that things are just harder for you for no good reason).
Two people very close to me are fucked without medication. My wife was anxious to the point of having regular panic attacks, which caused exhaustion and spirals of depression, and her fear of panic attacks was so great that it caused more of them, and made her want to die. With medication, she simply doesn't have them anymore.
My brother is bipolar and has to take lithium (and maybe something else) to stay normal. We've had a couple of emergencies where he's run out of medication or tried to ween off of it (once at the suggestion of his psychiatrist, the fucking idiot), and things deteriorate quickly, going from doing incredibly well to being so paranoid at work he can barely hold it together.
Not really sure how their personalities could cause these problems? Even if they are personality defects in some way, those aspects of their personalities must be suppressed or they simply will not function and would probably ultimately be miserable until they just killed themselves. It isn't necessarily a helpful insight to learn that a disease if part of _you_.
Regardless, I just don't think it makes any sense to ascribe these problems to personality, and the tendency to do so in the past led to many people being denied medication that could actually help them.
From experience, the brain is basically processing inputs (perceptions) and then outputs thoughts or actions.
The issue is when either the inputs are distorted or the processing is being interfered with.
Caffeine for instance can induce psychosis in some people by indirectly effecting dopaminergic response (via its action on adenosine receptors).
Other drugs can do the same. (we all know that marijuana can induce "bad trips").
But really, everything we perceive are inputs that can startup brain work. And some inputs are stored in memory.
One thing that can work is metathinking, i.e. awareness of one's own brain processing (observing one thoughts and bodily sensations for instance, basically meditation).
That's the processing part but one should also avoid distortions by avoiding psychoactive substances (alcohol, tea or coffee included).
Psychiatry doesn't work too well because it is underfunded and is stuck on alleviating symptoms. Psychiatrists are the first to admit that they don't really know how things work.
There are some weird stuff that can be discovered at the brain level once someone monitors their own thoughts/ brain chatter but this is somewhat esoteric. That's the realm of yogis, qigong practionners etc but there is too much folklore and I won't delve into that. Doesn't seem scientifically proven although I have my own experiences.
I’m not anti medication. It’s practical, and there seems to be a genuine biological aspect to a lot of mental illness. But I think we rely on it too much in America, and personality accounts for more than we give it credit.
‘thousands lines’ of gossip to not inform the reader about psychoanalysis…
which personally i hope starts to get less and less popular! giving placebo to patients that can suicide, for me, should be considered as homicide if recommended BEFORE any other type of treatment with a rate greater than “eating blades of grass” and thinking you are cured or will be cured
As someone who’s had life-changing improvements as a result of psychoanalytic therapy, when more “conventional” therapy like CBT and DBT nearly made me kill myself, please kindly keep your closed-minded BS to yourself.
science does not have answers to everything and it admits that. plus different psychologist, different results! you can not blame an entire method just because you tried once or twice! there is ton of ways of approaching CBT and DBT which may work or not for you
now do you think is BS to repress some form of treatment that can not get any valid proof and its rate of success is equal than a placebo?
* plus i said it should be considered a crime recommending BEFORE any other type of more-prone-to-solve-your-problem method
The reality is that both models work together. The amount that each side contributes in a certain individual is dependent on their circumstances and their genetics.
Depression is very much a chemical thing, look into the "comedown" recreational users of ecstasy feel after a night of rolling. MDMA is a stimulant that also excites the same receptors many classic antidepressants work on. MDMA effectively increases the effectiveness of Serotonin and Norepinephrine, the effect on Serotonin is uninhibited and is what causes the "high". After the "dump" of Serotonin into the brain, the brain recalibrates and the baseline Serotonin from before feels like less than it should for a few days. The symptoms are classic anhedonia depression. Clearly an imbalance causes depression.
Depression is also a very situational and mental thing. The traumatic loss of a loved one for example causes deep depression in many people. Even a breakup after a long term relationship can cause deep depression. Therapy and psychoanalysis can help someone become more mindful of their thought patterns. It can push someone to get past the immediate hurdle and regain momentum to live a happy and fulfilling life again.
Neither answer is complete. Trying to find a generic solution is part of what is keeping Psychiatry closer to the blood letting ages of medicine rather than the fMRI scan age.
My personal experience has left me biased and jaded about the current state and future trajectory of Psychiatry and mental health management. Both from the medical professional side as well as from the society side.
It may be a cultural thing, I come from an Asian background and my parents have hung on to that culture. I have stopped bringing up the topic and will excuse myself from conversations when they bring it up because when I try to speak honestly, they treat me like I am trying to peddle narcotics. To them there is only a binary choice, either live drug free and "clean" life or fiend for drugs like an addict. The line isn't based on all drugs in general either, there's a very different stigma around psychoactive vs non-psychoactive drugs. Beta blockers for blood pressure is okay, but beta blockers for performance anxiety and general anxiety is not. I know it comes from a deeper belief system of not taking mental health concerns seriously.
Reading this article was interesting, because I didn't realize western medicine had the same faulty starting point.
I am lucky to have grown up in a time of computer assisted dental x-rays. It's a culture shock knowing how recently Psychiatry was still in the age of lobotomies.
The US still hasn't officially banned lobotomies. The oldest sister of President Kennedy, Rosemary Kennedy was given one in 1941. They continued to be performed officially until the 1970s.
How good are we at explaining large ML model outputs?
My understanding is not very good?
And that is with us having a very deep understanding of the hardware, software, algorithms, and mathematics involved.
Now let’s suppose that you run your ML model on a computer and you get bad results.
Two experts show up. One says that you have a faulty memory chip and that they can fix what is wrong with the memory chip and then the model should work.
The other says that because of the training data the model was exposed to, some of the weights are bad, and by providing focused new data for the model to train with, they can adjust those weights so the model produces better output.
While you are deciding, these two then get into a big fight each accusing the other of being a charlatan.
I'm unsure as to the thesis of this comment: what's your point?
Perhaps I just don't buy your premise. We understand ML models very-well, but we don't like the explanation. Models are on a spectrum from parametric where a data distribution is assumed, to non-parametric, where it isnt. In the non-param case, models largely remember compressed "averages" of historical data.
The sense in which we dont "understand" how, eg., a NN comes to a prediction is only in the sense that we cannot, a priori, locate the specific subset of historical data that it has taken a weighted average-of... but we know well that this is what its doing. ie., something incredibly dumb and boring.
> I'm unsure as to the thesis of this comment: what's your point?
A roundabout analogy which is supposed to liken the human mind to ML by showing that experts in both fields are equally perplexed at the two objects of study (ML and the human mind).
You see now how we are approaching human-like intelligence? ML experts don’t know what they are making or doing, just like psychologists and psychiatrists can’t communicate on their different models of the mind!
> just like psychologists and psychiatrists can’t communicate on their different models of the mind!
This is where the analogy breaks down quickly, though.
I realize that the article tells a story about extreme situations where the two were directly at odds, but that is not the state of the art in psychology/psychiatry.
Psychologists and psychiatrists routinely communicate with each other about their models of the mind, and collaborate on the appropriate course of treatment for patients.
For many of the same reasons that some injuries require surgery to fix a serious issue, medication to deal with short term pain, and physical therapy to rebuild the body.
And neither of them really knows anything, they just came up with reasonable hypotheses to explain observed behavior, figured out what to do about them, ran tests to confirm and then approved those treatments on the basis that they worked more often than not. What does this stuff even do? Not sure, they just have proof that it's effective.
> When his ex-wife moved to Europe with their two sons
It's hard to ignore that if the gender roles had been reversed in this story, the obvious response of everyone around the bereft despondent mother would have been: "give her back her children"
Sorry, you're right, and I'm sure there's more to the story and that the journalist took license in that introduction. Still it feels like a gratuitously tempting red herring, and the journalist could have toned down that intro story
It’s an interesting and clearly challenging point. But psychoanalysis is very important to me, and it rarely gets air time here, so I’m eager to protect this article from flame wars.
> Ray’s mother asked the Lodge to give him antidepressants. But to the Lodge psychiatrists the premise of this form of treatment – to be cured without insight into what had gone wrong – seemed superficial and cheap. Drugs “might bring about some symptomatic relief”, Ross, Ray’s psychiatrist, acknowledged, “but it isn’t going to be anything solid in which he can say, ‘Hey, I’m a better man. I can tolerate feelings.’”
I remember a HN comment from trained pharmacist (https://news.ycombinator.com/item?id=32103546) that argues the same thing: “I promise you that no drug that you can take can make any permanent changes to edit your mind”
Ray looked at two different stories about his illness, the psychoanalytic and the neurobiological, but both "failed him". I would say that the psychoanalytic story has a better chance of explaining his case, but for some reason he wasn't receptive to it.
Relatedly, the chemical imbalance theory of depression was disproved in a popular study published two months ago. Here is a good summary: https://youtu.be/TZhgvr2rbwE. But SSRI are still effective, at least in reducing symptoms. We basically don't understand why and how they work.