Comment by cassowary37 | Hacker News Reader

Comment by cassowary37 | Hacker News Reader

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Professor of psychiatry here - I've spent the past 20 years trying to help folks with depression, and related illnesses, and trying to study these diseases at a genetic level. I suspect this will get me down-voted as I know the medical/biological perspective is often unwelcome on hn. However: a key error people make here and elsewhere in speculating about depression (and suicide, and ADHD, and...) is either extrapolating only from their own experience, or from a vastly oversimplified psychology 101 perspective. For example: "Depressed people move more slowly, in a characteristic pattern called “psychomotor retardation”. Well, yes - except when they have agitated depression, characterized by psychomotor restlessness. Or, when they have neither of these. Likewise, oversimplifying by claiming it is a disease of dopamine, or serotonin, doesn't much help. When my car stops working, is it a disease of gasoline? Part of the challenge of depression is its very heterogeneity. What we need is not more theorizing, it is more recognition that we need better treatments of all sorts.

I would hope the opposite is true, and that medical expertise is particularly welcomed and appreciated on HN (you aren't the only doctor here). Thank you for taking the time to comment!

I’ve never been sure why it’s treated as a disease rather than a symptom. It’s like saying someone with a high temperature is suffering from fever. Which is nice and descriptive and treatable with the right medications, but does nothing to describe the underlying cause.

Lots of what we now consider symptoms were thought of as diseases until the underlying problem was better understood. It wasn’t that long ago that your fever example was how people thought. The fever was the disease regardless of the unknown underlying cause.

That depression is considered a disease by itself and not a symptom of many, possibly related, problems suggests how little we understand it.

In my experience and observation, the physical world of the subject has been far too discounted.

And, I'll add, there are manifold variances in personal experiences and circumstances.

Why? Well, among other things, and in a simple reduction: Because the physical world is a "hard" problem. And one that does not involve just the subject him-/her-self.

Actually, also, in my observation, often the "hard" part isn't a determination of what should or needs to be done. It's finding the resources to accomplish this.

For example, remove people from their circumstances and sources of -- often extreme -- stress! (Or, enable them to do this, once they elect to. And/or effectively deal with the sources, themselves -- as an individual, a community, a society, or whatever effective agency.)

Yeah, but...

So, you come up with, as a profession, professionally blessed compensation mechanisms and assignment of responsibility to the subject -- perhaps, the victim -- instead.

I'm not saying everyone does this. Nor that all cases reduce to it. But, it is well worth considering, as a part of the continuing problem of mental illness and its treatment.

Without commenting on content, I will point out that the author of the article is a psychiatrist as well.

Yes. This is one reason I bothered to comment. Psychiatrists who step into the public space bear a particular obligation both to advocate for our patients and to push back against misinformation.

The article is prefaced with: "Epistemic status: wild speculation." It seems like we rather do need more theorizing, because we don't currently have a theoretical description of depression that leads us to solutions. I know I've also seen him write about the possibility that depression is a set of interrelated diseases that look the same, and talked frankly about the inefficacy of treatments.

It's a fairly ungenerous read that would lead you to imply he's failing in some professional obligation. It's like discussing murder - how often do you need to state that you think murder is A Very Bad Thing? Do oncologists need to talk about how bad cancer is every time that they write about it in a public space? Eh.

>> Do oncologists need to talk about how bad cancer is every time that they write about it in a public space? Eh.

They would if a surprisingly large portion of the public believed cancer didn't actually exist.

"How dare you allow your malignant cells to unboundedly replicate! What would your mother say?"

He highlights the speculative nature of the theory quite frequently within the article. It would take pretty poor reading comprehension or deliberate misreading to conclude that he was presenting established scientific facts.

I don't think this article was meant to be widely shared, especially not in a public space like Hacker News. Alexander has a number of articles about depression grounded in actual established psychiatry and is, unsurprisingly, a big proponent of treating it - I'm not sure how you're getting "doesn't advocate for his patients" from this article. Also, it literally starts with the words "total wild speculation". It certainly looks like it's supposed to start a discussion rather than be informative.

There is Twitter and Facebook share buttons embedded in the article that was posted to a pretty high traffic blog...

Could they be several different illnesses with different underlying causes, but similar symptoms that mistakenly get classified under the same name?

Yes, that certainly could be the case. Unfortunately there doesn't seem to be much (if any) understanding of what is different about those illnesses, and in particular no practical test that can distinguish between them to help identify the proper treatment.

By contrast, it is now very well recognized that there is no single disease called "cancer". There are many subtypes, not just based on tissue (e.g., breast cancer vs. lung cancer) but also on the molecular etiology (i.e., which mutations are present in the tumor and therefore which pathways of oncogenesis are involved). Because of this, it is in some cases possible to determine based on DNA sequencing which is the appropriate drug to use to treat a particular cancer. Depression is not anywhere near as well understood.

There's an opioid epidemic sweeping the nation. If psychiatry has anything more effective for treatment than court-mandated AA (well, NA), now would be the time to do something, because people are dying left and right. Current treatment regimes are totally ineffectual. 30-days of rehab, along with religion-based and "addition is a moral failing" 12-step programs isn't cutting it.

It's not the number of theories that count, what counts is if there is a theory is actually useful in modeling results. If the car won't run and there's no gasoline, call it a disease of gasoline if you have to, but adding gas does wonders for my car actually running.

The late 1800's opiate epidemic called; they want to know if psychiatry has actually advanced in the interceding years.

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