[amputect]

I think that the United States is getting better about dealing with mental health, but we still have a long way to go. This is a little soap-boxy and anecdotal, and I apologize if it's inappropriate here.

If I hadn't gotten a prescription for Prozac I probably would have killed myself by now. And I definitely would have destroyed my marriage and most of my important friendships. That's not an over-dramatization, it's the honest truth just based on the direction my life was heading without them.

If you can't make your own neurotransmitters, store bought are fine. I'm not writing this to say "RARGH YOU MUST USE THESE DRUGS", but I absolutely am writing it to say "hey, this worked for me and got me out of a really dark and bad place". If you are reading this from a dark and bad place, please know that you're not alone. You have a lot of options, and I promise that if you take that first step, things can get better.

[jdietrich]

>If I hadn't gotten a prescription for Prozac I probably would have killed myself by now.

The majority of people with depression just get better of their own accord, for no obvious reason. The NNT for most antidepressants is ~7, meaning you need to give them to about seven patients for one patient to see a clinically-significant improvement.

The evidence suggests that there's no significant relationship between SSRI use and suicide risk except for young people, for whom SSRIs may actually increase the risk of suicidal behaviours and self-harm.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353604/

>If you can't make your own neurotransmitters, store bought are fine.

There is no evidence whatsoever that people with depression are "deficient" in neurotransmitters. We don't really understand the mechanism of action of any antidepressant. Plenty of drugs that have no effect whatsoever on serotonin are equally effective as SSRIs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471964/

Antidepressants can be useful for some patients, but they aren't miracle drugs - they aren't even particularly good drugs. If you're depressed then you should certainly consider pharmacological treatment, but you should regard it as only one tool among many. Talking therapy is equally effective and the combination of drugs and talk therapy is more effective than either alone. You might need to try several different drugs before you find one that works for you and has tolerable side-effects, especially if you have been depressed for some time or have comorbid conditions. If your depressive symptoms are relatively mild, you should probably look at lifestyle interventions like diet, exercise, sleep hygiene and self-help before considering drug treatment.

https://www.nice.org.uk/guidance/cg90

[tachyoff]

I agree with all of this, and I can’t help but ask: when did we start ignoring people’s environment and their circumstances? I have tens of thousands of dollars of student loan debt (my monthly payment is basically a mortgage payment) and I’m not particularly satisfied at work. Is it any wonder I find it impossible to get out of bed? Now, I try to be careful because, sure, perhaps the depression was already there and is just making my life complicated, but that seems less likely. I KNOW I’m not happy at work; I KNOW my debt burden makes me feel trapped and helpless. Look at Harlow’s monkeys. Turns out putting creatures in helpless, depressing environments makes them feel helpless and depressed. If seeing your friend get blown up by a roadside bomb can give you PTSD, couldn’t falling wages, no social safety net, stressful news media, crushing debt, and poor job mobility make you depressed?

[jdietrich]

a) We're a highly medicalized society with very weak institutions for providing informal psychosocial care and support.

b) Saturation marketing of psychiatric medication has caused the general public to grossly over-estimate their efficacy, even in countries where direct-to-consumer marketing is banned.

c) The wholesale price of a generic sertraline pill is about 4¢, so it's cheap enough to dole out like candy.

d) Medicalizing unhappiness is politically convenient.

If you're depressed, you go to your doctor. That's the message you've been told for decades, it's how our society is set up. In another culture, you might speak to your priest or a village elder. It's undoubtedly a net positive that we've got access to some kind of evidence-based psychiatric care, but a lot of the other structures that people used to rely on for psychosocial care have crumbled. We're less likely to know our neighbours. We have fewer close friends. Our employment is more impersonal and precarious. We're less likely to go to church. If we do go to church, it may well be a megachurch with a congregation of hundreds rather than a close-knit community church.

Doling out pills is the absolute cheapest treatment option, even if some proportion of those pills are expensive proprietary drugs. It's orders of magnitude cheaper than psychotherapy and immeasurably cheaper than building a more humane society. Your doctor can't prescribe a good friend, a sympathetic partner or a better job.

It suits your employer if you conceptualize your misery as the symptom of a "neurotransmitter deficiency" rather than a symptom of your crappy job. You probably won't be as productive, but at least you won't go on strike or burn down your office. It suits the government equally well if you see misery as a personal rather than societal problem.

Some people are just depressed for no discernible reason. Lots of people are being diagnosed with depression when they're just struggling with a shit set of circumstances that would make anyone miserable. The medical model helps some number of people in both camps. Society needs to do a better job of helping people live healthy and fulfilled lives.

[nerfhammer]

This is essentially the learned helplessness theory of depression: https://en.wikipedia.org/wiki/Learned_helplessness

[markroseman]

We're not ignoring their environment. But unfortunately, most of the time drugs are quicker and easier for the prescribers, and therefore cheaper and more available for the patient, than extended psychotherapy, etc.

If the underlying problem is a psychosocial stressor, the meds won't fix that, though they might help you control the symptoms long enough that they give you the opportunity/resilience to address the stressor. And sometimes, while maybe not ideal, just controlling the symptoms is enough even for the long term.

[hestipod]

"We" absolutely are ignoring their environment in the USA at least. People cannot even access healthcare here without additional, significant financial stress and burden. My entire family and the strong majority of my region and a general majority overall oppose the policies and systems that would give someone like me a life and future. Even seeing how it's gone for me my family refuses to support social systems and offer help to those in need. It's "stealing my money" to them and ruined our relationships seeing how selfish they are turning their back on me AND society.

I know the causes of my issues, there are at a minimum mitigations available but I can't BUY them because everything here is a business and competition and someone else took me out of the race by taking lots of money to end my capacity to compete (poor medical intervention) and I was left holding all the additional baggage with no help. I have friends who suffered catastrophes living in countries who don't think social systems are evil, and they had the tools to heal as much as possible and improve their lives and be able to contribute to the whole again. I wasn't afforded that opportunity and it's been a constant downhill slide.

Pardon the tone and it is not directed at you, it just infuriates me that American society ignores such important things and once someone is not able to WIN in the Thunderdome they are cast aside and/or expected to live with little to nothing and even more needs, while it continues focusing on pushing what are in my view largely ineffective, but very profitable "interventions". I find the predilection for painting over damage in this country over restoring/shoring up someone's foundation to be maddening.

[hmhrex]

This is the main reason I stayed away from medication for 12 years. That is until 3 weeks ago.

I decided late 2017, after a major depressive episode, that I needed to get help after 12 years of dealing with this depression. I kept thinking that I had a handle on it, and then it coming back weeks, months or years later.

I read The Depression Cure (https://www.amazon.com/Depression-Cure-6-Step-Program-withou...) about 5 years ago, and it helped for awhile, but it started to worsen again, and after awhile, getting the right diet, exercise and sleep seemed impossible because of the depression and anxiety.

I started therapy about 3 months ago, and finally agreed to try medication. I started taking Zoloft 3 weeks ago, and the side effects are downright awful. I made it through the first 3 weeks though, and I'm starting to feel a lot better.

Zoloft might not end up being the right medication for me, and there might be a better one, but my goal is to find something that takes 10%-20% of the depression and anxiety symptoms away so that I can start my path to curing this beast with the methods Dr. Iliardi outlines in The Depression Cure. Once I'm at a point where I'm better, I'm going to try and ween off the medication and try to live a healthy, great life without SSRIs.

[Jugglerofworlds]

For the more severe anxiety disorders, the proof of efficacy above placebo is much better than what we have for depression. People don't get better by taking placebos for their OCD. For anyone experiencing anxiety problems, I highly recommend finding a competent therapist who knows CBT. For anxiety that constantly interferes with daily life, medication may be appropriate.

For me the SSRIs completely wiped out my OCD to the point where I sometimes forget that I have problems with anxiety. Depression is downright benign compared to how bad the situation can get with other psychiatric disorders. Unfortunately the demand for competent medical professionals far outstrips what is available.

I do agree that SSRIs are over-prescribed for minor depression problems, but let's not demonize a whole class of medications which are highly useful for more serious psychiatric issues.

[hmhrex]

Some people need it because their brains is just plain imbalanced, I get that. For some, that imbalance can be fixed with lots of work, however for some, it can't. I'm _hoping_ to be able to fix mine, but I'm willing to work with a doctor to figure out if that's possible.

[WalterSear]

> Depression is downright benign compared to how bad the situation can get with other psychiatric disorders.

No - you just have no experience of comparably serious depression.

[ChristianGeek]

I wish you the best. Definitely don’t be afraid to discuss alternatives with your doctor if you’re not happy with Zoloft...sometimes it takes a few tries before you find whaat works best for you.

[hmhrex]

Thanks for the reminder. I'm trying to tough out a month, because side effects tend to wear off within 3-4 weeks, and review with my doctor and therapist then.

[tyrex2017]

NNT might be 7 for one drug and one try, but the therapist will try several drugs and doses.

I could imagine that NNT might significantly improve if you consider “use antidepressants” instead of “use 1 antidepressant 1 time”

[jdietrich]

Assuming that efficacy is randomly distributed, you're left with some very frustrating math. You'd need to try five drugs to have a better than 50/50 chance of getting a positive outcome. After seven drugs, there's still a 34% chance that none of them have worked. After fifteen drugs, there's still about a 10% chance that nothing has worked. I expect that most patients will give up on drug treatment well before that point.

I don't want to be overly negative about antidepressant drugs - they're a useful treatment for many patients - but I do feel that the popular perception of their efficacy is far greater than the reality. Many people seem to feel extremely disheartened when antidepressant drugs don't work for them, often believing that there must be something uniquely wrong with them. The language of psychiatry doesn't help, describing these people as "treatment-resistant" rather than "people we don't know how to treat".

If you try antidepressant drugs and they don't seem to do anything, don't keep taking them just because you think you're supposed to. Speak to your doctor about alternative drug and non-drug treatments. If you have access, try a range of psychotherapies. If your symptoms are relatively mild, look at lifestyle interventions. If your symptoms are particularly severe and/or chronic, give some serious thought to rTMS or ECT.

[tyrex2017]

i agree with your points, but 50% is already good i think.

it is less than anyone might spontaneously guess, but it is still good, considering that you will try a couple of other things in addition, like cognitive therapy.

So getting some good months long treatment by a doctor can lead to (lets say) 70% curation rate. It then becomes sad if people choose to stay away from doctors and I just commented to not discourage possible ill persons.

You probably just wanted to stress that such pills are far away from doing guaranteed miracles and you are right.

[alex_hitchins]

> The majority of people with depression just get better of their own accord, for no obvious reason. The NNT for most antidepressants is ~7, meaning you need to give them to about seven patients for one patient to see a clinically-significant improvement.

Which is fine, as long as they stay alive long enough for natural changes to occur. If a prescription gives only hope, that could be enough to keep people strong enough to battle through another day, week, month, year.

[jashpool]

>The evidence suggests that there's no significant relationship between SSRI use and suicide risk except for young people, for whom SSRIs may actually increase the risk of suicidal behaviours and self-harm.

The paper says: "However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides."

[publicfig]

As someone in the very same boat, I appreciate and can relate to the line you have to walk. My life was positively changed by going on Prozac in a way that I didn't think was possible. After years and years of trying any way of dealing with depression that didn't involve medication, I was absolutely at a dangerous place. Most of my reasoning was that I didn't really believe in the efficiency of medication, and even if so, I didn't think I was actually someone with depression, just that I had been, since i was a kid, putting myself into constant situations that caused severe anxiety and depression. It didn't all work at once, and I had a lot of weird steps between starting and being in a state that I would now consider "my normal self that I never knew I actually was", but it's been an overall life changing experience.

That being said, I understand that medication, or even the same medications, can't work for some people in the way they did with me. It's difficult to explain the position of "I know medication doesn't always work and isn't always an answer, but sometimes it is an answer that I would hate to be missed out on".

[evincarofautumn]

Likewise, if storebought doesn’t do the trick, some people (myself and my partner included) have better luck with the recreational variety—mushrooms were the thing that kicked me in the psychological ass and started me on the path to recovery from alcoholism (which was partly self-medicating for anxiety). To be clear, this is absolutely not something I’d recommend lightly. Taking (who knows how strong) mushrooms or LSD isn’t exactly the most precise or reliable way to go about it, and there are attendant risks.

I just hope in the future there’s more access to psychedelics (and analogues) in a safe, professional setting, because they’ve been shown to be another potentially useful tool in the antidepressant/anxiolytic/self-care kit.

[tyu100]

This study, along with long-accepted clinical practice and the generic cheapness of most anti-depressants now, and the effectiveness of CBT/therapy if it's available to you, means you should really avoid self-medicating for major depression.

Why take risks with your health when there are lots of safe, cheap and efficacious treatments that can be monitored by your doctor?

[soundwave106]

The poster asked for "access to psychedelics (and analogues) in a safe, professional setting", which ideally (if the treatment is one that indeed works and isn't placebo) would be one that is monitored by your doctor. I agree that self-medication is not idea.

The issue here I think is that most current anti-depressants are currently of the SSRI / SNRI / tri-cyclic class. These treatments work great for some people, but do not work for everyone.

In one case (ketamine), this particular hallucinogenic drug has emerged as a candidate for anti-depression therapy (at least in mechanism) that works quite a bit different than the above (acts on glutamate). Non-hallucinogenic glutamatergic anti-depression drugs are being developed as a result, but as one is well aware, this takes time. Until one of these drugs emerges (rapastinel seems furthest along at this time), off-label ketamine clinics do exist where you can take the drug with some degree of clinical supervision.

I have not seen too much on the serotonin agonist hallucinogens in the past relieving depression, but Googling, there does seem to be a newish article on psilocybin (https://www.nature.com/articles/s41598-017-13282-7) that suggests it does offer a possible interesting anti-depression mechanism too. Possibly more exploration is needed here to confirm whether it works well (or not) and, if so, how.

I don't think we've even come close to exploring all routes to resolving depression, so I think exploring as many routes as possible is a good path. (And I do think scientists are doing this -- the parent article was for instance the first time I've heard of a melatonin receptor agonist as an anti-depressant candidate! https://en.wikipedia.org/wiki/Agomelatine )

[joncrane]

One issue worth mentioning is that psychiatrists are one of the hardest specialists to find that participate in health insurance. This is only anecdotal in my area, but many that take insurance have multiple month waiting periods for new patients. Or you can pay $200 to see one on your dime.

It's not the cost of the medication that's the problem. It's access to the professional to prescribe the medication that drives people to self-medicate, IMHO.

[PhasmaFelis]

Ditto. Also, at least for state-provided health insurance, there seem to be quite a few that accept it but aren't on the state's registry for some reason, so it's worth calling and asking.

[aianus]

Psychiatrists have a three month waiting list here in Canada and therapy is $100/h.

[markroseman]

Three months in some places. Here in Victoria, unless you're in crisis, it's actually almost impossible for most people to get in to see a psychiatrist, and if you can, the waiting list is well over a year.

[evincarofautumn]

I generally agree—I guess I just mean I wish there were a safer/tested way to take advantage of other serotonergics, after the first line of defense fails, for those who are less cavalier than I am about their neurochemistry.

Also in my case it wasn’t depression, so I can’t really speak to that, but SSRIs are also prescribed for anxiety disorders. I chose not to go on them when they were offered because I didn’t feel that the side effects were worth it, and they weren’t the correct treatment anyway because at the time I was mainly anxious due to alcohol withdrawal. (I’m lucky I didn’t have a seizure!)

[WalterSear]

Because they aren't safe, cheap or efficacious.

[hestipod]

I'd like to expand a bit and reiterate that not everyone who suffers from depression has primary depression with no discernable cause. Most seriously depressed people in my experience have various situational causes (physical health, financial, social etc) and the depression is a side effect of those and not the main issue. Without tackling the root cause, drugs usually just cover, drag out, and add issues, yet the mental health system mostly uses these drugs as a blunt instrument and fail to address the cause. In the right circumstance, and right conditions, they CAN enable someone to get out of a rut and take actions they wouldn't have without so they do have a place after someone with unexplainable depression who has tried less invasive and risky options like lifestyle changes.

I am not encouraging people not to try medication if they feel it is a good option, simply asking people to realize A. It's not a cure without a plan to fix the cause and B. Not to follow the common victim blaming that often occurs when these simple "fixes" don't work for people (OP isn't doing that and I don't intend to sound as if I am saying so...in fact they made it clear it's not a magical fix suited for all) Drugs are a tool, not a cure, and need to be wielded responsibly and properly. Sadly I don't believe that happens a lot of the time.

[branx]

Jordan Peterson talks about this in one of his lectures. I can't look it up now but if you google "Jordan Peterson antidepressant" you should find something

[analogmemory]

> If you are reading this from a dark and bad place, please know that you're not alone. You have a lot of options, and I promise that if you take that first step, things can get better.

I really think they need to have some sort required of "Life Skills" class in high school. In which they teach you how to get help, how to ask for help, how to share your feelings with friends in a safe way. And your options if you do get into a deep dark way. Based on personal evidence, almost every adult gets depressed in some way and many don't know how to get help or deal with it in a healthy way.

I didn't learn any of that till my 30s. I nearly committed suicide multiple times. Our current society and the toxic religious one i grew up in taught me that a man needs to be strong and doesn't need to rely on others. Pray to God and just pull yourself up by your bootstraps mentality.

It's amazing how helpful it is to know that you are loved and cared for. And people want to help you. You just have to ask for it.

[anticnstrctv]

Attitudes towards mental health in the US and the west in general are quite frustrating, and I hope they are improving. On the right there seems to be a tendency to deny nuanced views of mental illness from economic, religious, or simply conservative cultural motivations, or to push sedative (using this term metaphorically) medication as a panacea. On the left there are many influenced by the (understandable but deeply destructive) anti-psychiatry movements who both affirm mental illness and deny proper care. It is quite frustrating to see someone talk about their own "undiagnosed mental illness" while citing Foucault to disparage people you care about for seeking psychiatric methods that, as you described, saved their lives.

[markroseman]

The anti-psychiatry folks are extreme enough that they deny mental illness altogether, though many other "psychiatric survivor" communities do not deny, and often celebrate "lived experience", but are critical of psychiatric treatments.

[alex_hitchins]

I know exactly where you are coming from. Me too. Thank you be being honest and sharing your experience.

[imperio59]

Just because it worked for you doesn't mean it works for everyone, actually by far you're the anomaly... See https://nypost.com/2016/04/05/are-antidepressants-making-wom...

Also would you say the drug cured you? Are you able to function without taking it now?