Most people on antidepressants don’t need them | Hacker News Reader

Most people on antidepressants don’t need them

economist.com

121 pointspseudolus155 comments

Statements like this need to be worded very carefully. In many people's minds, saying something like "most people don't need antidepressants" quickly becomes "antidepressants are useless". Many people who may benefit from them get scared away.

Speaking as someone who has been on/off antidepressants for GAD+OCD for the better part of a decade, I've had countless people tell me that antidepressants are useless and just placebo pills pushed by Big Pharma. But for me, they are life changing. They turn me from someone who just sits indoors having panic attacks all day to someone who can live a relatively normal life. I've tried (and continue to have) therapy, but SSRIs are wonder drugs for myself and many other people.

The caveat is, you often need to try 2 or 3 different SSRIs before you find one that works for you, and if you're unlucky, you may not find one, or the side effects can be intolerable. For me, I tried fluoxetine and citalopram, neither of which really worked, but sertraline changed everything almost overnight. The only side effect I've experienced is weight gain, which isn't great, but is better than the alternative.

However, this is the UK which may have a different attitude to the drugs. Before and during initial treatment, I was provided with around 20 behavioural therapy sessions, and even now I still have quarterly drug reviews with a doctor. At no point did I feel like I was being pushed onto SSRIs, and they checked to make sure it wasn't something environmental that could be easily remedied before asking if I would like to consider medication.

For what we've been reading this last years, it's not like antidepressants are worthless, it's like antidepressants aren't doing what we think are doing.

The "depression is lack of serotonin" theories seem to have less and less base every day, but SSRIs don't only act on serotonin (just review their side effects).

I've done, mostly, vortioxetine and sertraline. For some of us, some SSRIs or SNRIs work. Some don't. Probably it's not because of the serotonin. They have weirdly different effects depending on the person. But there's something going on that we still don't understand. Both because we don't understand the whole mechanism of depression, nor WTF the SSRIs and SNRIs are doing in our mind and body.

At least in my humble opinion.

Depression, OCD, GAD, ADHD and most other neurological issues stem from complex feedback loops and deficiency in neurotransmitter systems.

They're labels applied to symptoms, not causes.

Like any complex system with feedback loops, sometimes intervention in the loop causes it to rebalance.

Sometimes the loop break is an intervention in serotonin, sometimes dopamine, sometimes GABA.

There is never a silver bullet. But there are bullets that make life manageable enough to break cyclic issues.

I completely agree. I believe we have no idea how these drugs work at the moment.

For one, serotonin receptors are _everywhere_, notably the gut, which also has a strong relationship with emotional state. And as you point out, they don't just affect serotonin. Given we have a whole bunch of drugs that attempt to be serotonin selective, but where each one affects different people in different ways, it seems likely to me that the non-serotonin effects are likely significant.

Plus, what's the reason so many of us are anxious, depressed, neurotic, autistic, ADHD, etc. without obvious cause? Why would a huge chunk of the population have a imbalance of brain chemicals?

Ultimately I suspect my GAD/OCD is probably environmental, but environmental in a way that I can't easily identify or fix. Maybe it's the unnatural desk job oriented lifestyle I have, or maybe it's plastics in my blood, processed foods, lack of religion, social media or something else. Or maybe the neurotransmitters just sometimes need a kick up the arse to get them back into proper functioning.

All I really know is sertraline helps me live a normal life, and for that I'm thankful.

> Why would a huge chunk of the population have a imbalance of brain chemicals?

That's what I think about from time to time as well. I have ADD and take meds for it. But I'm pretty sure that I only need these meds to be able to work in an open-space, corporate IT environment with dead-lines, responsibilities etc.

Without meds I get overwhelmed and panicky quickly, when taking them they turn me into kind of an office robot who's able to work without getting too stressed out or distracted by other things.

I suspect that I wouldn't need the meds if I had a different job. Which feels weird, because it sounds like I'm trying to fit into an environment, instead of being in an environment which fits me, if that makes sense. Then again, maybe everyone has to do that and it's just my biased perspective that I'm the one who's not made for it.

Which sucks, because I love IT, also as a hobby.

The easiest examples for that: Sometimes I do an IT project at home, maybe build a PC, configure a homelab, try out Stable Diffusion or edit videos from time to time. If I do these things at home I can easily sit in front of the computer for 5+ hours and loose track of time, but I don't seem to be able to be as focused for IT projects at work if I'm unmedicated. Unless they really interest me.

I believe the same thing. In fact, I believe people with ADD have a natural advantage in pre-modern settings. We are built to run long distances, outsmart prey, and forage. A distraction isn’t a distraction on that environment, it’s awareness and quickly thinking through possibilities and avenues of success.

If anything it is more of an attention surplus than an attention deficit.

This is a point that Dr. Richard Barkley, one of the major researchers in ADHD in the last few decades, has stated slightly differently. In a sort of jest, he mentions that [ADD] should be called “intention deficit disorder” as there is plenty of attention to be given to things, sufferers just lack a lot intentionality behind their actions. This ultimately manifests as an executive disfunction which prevents this slice of the population from subconsciously knowing how to prioritize or assess the importance/value/urgency of stimuli.

> I believe people with ADD have a natural advantage in pre-modern settings

Totally, yeah. I can't prove it of course, but I've noticed countless of times that I seem to be extremely more aware of my surroundings than my friends etc. I hear and see more compared to them, which has positive and negative sides.

Same here, man. It’s for the reason you described in your first paragraph. Working in a soul sucking corporate office space is so painful for certain personality types.

For me at least, I’ve always thought it would be cool to be a delivery driver or someone who’s out and about everyday moving around… but I stuck with IT because it makes astronomically more money.

So sitting at a desk all day will require me be medicated because my baseline preference is to be up and moving, working with my hands, talking to people, etc.

I think a lot of people with ADHD that’s severe enough to require medication are just people who don’t do work that truly fits their personality.

Which if we’re being honest, sitting at a desk all day is not natural. I never needed Adderall when I was working in a warehouse in college, or when I was a city guide that was supposed to walk around downtown and greet people.

tl;dr Unnatural lifestyles require unnatural supplements.

As your sibling post pointed out I think our adhd was a benefit in preindustrial times, or at least in preagricultural times.

And a desk job with a fun coding project to do (fun coding usually doesn't pay as well) was fine for years. Hyperfocus was nothing but upside except for having to do taxes or do he occasional tedious task.

But when you get too good at your domain, and you have 10 unrelated coding projects, even if they are all fun, adhd is no longer your friend. #include wife and kids and doctors appointments and birthday parties and ... Adderall helps now. I need to turn off my hyper adaptation quite often now.

By will alone I set my mind in motion, but I need amphetamines to slow it. It is like we were born as mentat and instead need drugs for everything except that.

Hear, hear. There's a lot of us in this same boat. These asocial, sedentary IT jobs + hectic lifestyles are out of sync with our biology and psychology.

I didn't know it at the time, but I was in the same situation for years. I started doing blue collar work at mine sites and oil/gas pads. For me, it's a good fit. And the people are real.

>Why would a huge chunk of the population have a imbalance of brain chemicals?

Because they are all members of a society whose food production is controlled by 2 or 3 mega-corporations, who also, incidentally, have an interest in selling pharmaceutical products to make people feel better about their lives ..

That's quite a huge accusation, do you have any evidence to back that up at all?

Cause if I understand the implication correctly, you're basically saying that the 2-3 megacorps who control food production (which is already far from true, IMO) are literally poisoning people to cause them to need antidepressants.

Are pharmaceuticals food?

https://www.theguardian.com/environment/ng-interactive/2021/...

Americans eat the most hyper-processed food on the planet. They're also over-prescribed with anti-depressant pharmaceuticals. Causation/Correlation? You decide: move outside the scope of Bayer's and Monsanto's reach, and see for yourself how less depressed you feel on a daily basis after a few months of real food ..

Final word: Nestlé.

Is there anywhere outside their reach that doesn't involve giving up all the other benefits of the industrial revolution? I'm not a Luddite, I like labor saving devices andblife saving procedures, and even some medicines.

You assume a lot of competence on the part of these large actors to collude and conspire at the macro level.

Let’s assume, for sake of argument, the conclusion of your assertion is true in that we are being poisoned and offered medication to mitigate the effects of said poison. This is more likely the effects of independent actors acting upon their respective self-interests.

Food companies try to drive costs down to sell cheaper products at the same price, which may end up having poor health consequences by virtue of untested substances having mass exposure. Pharmaceutical companies respond to market forces by developing drugs they can get funding for, which usually ends up being ailments that a lot of people have. There are way more efficient ways for them to team up and make money, this is just a side-effect of large institutions acting in self-interest.

> what‘s the reason so many of use are anxious, depressed, neurotic, autistic, ADHD, etc. without obvious cause?

Because modernity hasn’t been an unmitigated success. In the pursuit of abundance, we’ve made all sorts of trade offs that we are now realizing have had unintended consequences to mental and physical health. Every leap forward has felt like progress but has underlying negatives. The world has trade offs!

The move from agrarian to industry to service/knowledge based economies, as an example, has produced countless benefits, but as another commenter mentioned: sitting at a desk certainly isn’t as healthy as moving in the fields. Being in big urban environments to facilitate the new economy has produced amazing culture and a more inclusive community, but at the cost of tight-knit lifelong social networks, noise and air pollution, crime, etc.

I’m not saying yesteryear was better - I’m pointing out the trade offs that were made and how we are now recognizing some of the costs. Perhaps the pendulum needs to swing back to some degree to ease these costs if we as a society aren’t happy with the price paid. There is a return policy!

Mental illness is not a byproduct of modern society, its study and treatment is. Why is the rate of mental illness going up? It's because the stigma over mental healthcare is dropping rapidly and more people are getting formally diagnosed. That's like saying schizophrenia didn't exist in antiquity, people were just attacked by actual demons and everyone else was "normal".

>Mental illness is not a byproduct of modern society, ...

I didn't state that it is solely caused by modern society.

> Why is the rate of mental illness going up? It's because the stigma over mental healthcare is dropping rapidly and more people are getting formally diagnosed.

Source? Or is this just a theory like mine?

"Mental illness is not a byproduct of modern society, its study and treatment is. "

If you have data on the incidence of depression in hunter gatherer societies we can compare to modern societies feel free to share it.

"Why is the rate of mental illness going up? It's because the stigma over mental healthcare is dropping rapidly and more people are getting formally diagnosed."

So in your mind the functioning of a society has no impact on the rate of mental health problems?

Exactly this and I have suspected for years now there is a huge gut connection. I am not saying it is the only cause (or even the sole cause) but I do believe for a lot of people it is exacerbating the issue significantly. The gut also has tons of opioid receptors and there are some scholars who now consider the spinal cord to be a serious part of the brain - and the spinal cord directly branches out in very large nerves all over the gut.

I personally notice a large positive change in my mental health when my gut is functioning properly and I am eating the right fermented foods. I do not take SSRI's and have not been diagnosed with major depression. I also find it hard to believe that it is a coincidence that as a species we have been eating and making fermented food for so long and so suddenly discontinued its use in a widespread way and are now seeing increases in many types of disease. Although lack of exercise may very well also be a huge contributing factor.

> The "depression is lack of serotonin" theories seem to have less and less base every day

But that is not true.

The problem with statement "depression is lack of serotonin" is the same as with "being overweight is due to eating too much". It is factually true, seems like an easy solution and yet is mired with lots of problems.

The problem with medication is that it treats the symptom (lack of serotonin) rather than the underlying problem (how did we get there in the first place?) Kinda like telling somebody to loose weight by restricting their diet before first understanding what caused them to gain fat in the first place. Is your diet composed of garbage? Why is it, is it because you can only cook garbage? Is it because you can't cook and only buy garbage? Is it because you sit whole day and don't exercise? Is it because you are getting depressed and make it up with food?

The treatment should address the causes of the problem and not just the symptom.

This sort of echos my criticism to the way pharmaceuticals are developed, tested, and regulated. They all treat symptoms and not fix problems. Modern medicine has really advanced in treating acute issues (broken bone, laceration, benign pain) but is shit with chronic issues because it’s focused on symptoms. We prescribe statins the moment someone’s cholesterol goes too high, but did we ever stop to figure out why it is so? Maybe it’s because this person’s favorite breakfast is a bacon-maple donut which they habitually consume 5 days per week. What we are really saying is that it’s okay to eat that cholesterol-raising food, just take this to make that number lower.

We’ve optimized our efforts on treating symptoms and not causes. Drugs that survive regulatory scrutiny and are profitable tend to be those that treat symptoms of chronic illnesses. If you can prove that someone’s LDL goes down and they will buy it for the rest of their life, that’s a drug that will survive. They don’t have a miracle cure for this because they are withholding anything, there is just no incentive to research it and if there was, there is no good way to prove that drug X will cure non-visible condition Y without good, measurable data.

I think part of the reason is that there is lots of money in treating acute symptoms with medication while there isn't much in having serious talks with patients to try to debug their lifestyle problems that might be causing their health problems and then educate them on what and why they should be doing it.

I also think people naturally tend towards easy and fast solutions even if those solutions are known not to work. This self imposed blissful ignorance is what causes people to keep buying weight loss supplements or go on diets even though both are known not to work while we know that for 99% of people there is a simple solution -- reduce stress, learn to like to eat healthy and exercise daily.

> What we are really saying is that it’s okay to eat that cholesterol-raising food, just take this to make that number lower.

Realistically this is what most people want. I spent years watching people choose to go on medications rather than make simple lifestyle choices. Habits are powerful.

It’s not possible to treat the cause when a patient wants the easiest solution. So yea, we have a bunch of medication‘s that treat symptoms. Causes are sometimes impossible to know, the body is complex enough that we don’t even understand how some medications work at all.

+1 for sertraline.

One caveat is that you should ideally use them to get out of a funk and then discontinue if possible.

At all times get a psych you who trust.

Another +1 for Sertraline. It worked wonder for me after 2 years of depression (classified as mild to severe using some clinical test).

I've been taking it for 4 months, and since my life has gotten back to normal my doctor has advised tapering off of it, starting today. We'll see how it goes.

I thought it was standard procedure to advise trying tapering off if your life got back to normal, and see how it goes (at least that's how my doctor presented it). I guess that's not a worldwide standard though.

That's right, you are among the 0-15% SSRI's help. For the rest 85-100% of people they help as much as a sugar pill.

> Statements like this need to be worded very carefully. In many people's minds, saying something like "most people don't need antidepressants" quickly becomes "antidepressants are useless".

The statement is factually true and worded correctly.

But that's not enough. You have to give at least a little consideration to how your audience will interpret your words.

> Statements like this need to be worded very carefully.

I had a whole thing typed up, but deleted it, because I really only had one question: How would you word it differently?

To me it seems a carefully worded as possible, while still alerting to the fact that a class of drugs with terrible side effects are being massively overprescribed.

>But for me, they are life changing

This is not something you can claim. How could you possibly know that the SSRI is responsible for your recovery?

I'm not going to say that antidepressants are useless, but it is important to understand how placebo works. The key point is that placebo works and it is impossible for an individual to distinguish between a placebo and a life changing drug.

In antidepressant studies, SSRIs often outperform placebo to a degree. However, the placebo group has an excellent recovery rate! That means there are people who are clinically depressed, suicidal etc. who are then given a sugar pill as part of a study and make a full recovery.

>You often need to try 2 or 3 different SSRIs

That makes it even murkier. SSRIs take a long time to work, and if you try several of them that's going to take months to years. There's a high probability that in that time, you might naturally recover. You have the combined benefit of placebo and waiting in addition to the effects of the SSRI. You tried 2 SSRIs that didn't work. What makes you so confident that it was the third?

Again, I'm not saying SSRIs are useless. But it's important that we rely on controlled studies to make these determinations. Personal experience and anecdotes are beyond worthless; for example they are the reason why homeopathy is a $20 billion dollar industry even though it is actually provably useless.

> This is not something you can claim. How could you possibly know that the SSRI is responsible for your recovery?

This is the kind of trash thinking that makes it hard to get potentially life-changing medication. I take a heavily controlled substance for a sleep disorder and ADHD and our laws surrounding it’s distribution and refill are unconscionable. My life falls apart when there is lapse in medication and nobody takes it seriously. I cannot stay awake, focus, or function after about day 5 without it. It’s appalling that peoples’ well being is in danger every month because someone decided that it might be abused and restricting legal distribution is the solution for this.

First, you do not and cannot know what this person has been through or know what their baseline is. Second, if someone’s life is improved when taking a medication, what does it matter to you that they take it? I’m not going argue the efficacy of the family of SSRIs, but we need to let patients make their own decisions and assessments of what works for their situation.

Your "controlled studies", to mean anything at all, depend utterly on accurate, specific diagnosis. But for most of these conditions, the only way to get any specificity is to note which medications help. Absent any way to produce accurate, specific diagnosis, such trials are a waste of time and money.

> How could you possibly know that the SSRI is responsible for your recovery?

By noticing their effects? Seriously, what kind of condescending question is that, implying people can't tell severe differences in their own state of mind. Disregard it as "beyond worthless" anecdotes as much as you want, when this stuff works it's very clear and not some "might be placebo" kind of deal, including remarks from other people who notice the changes.

> That makes it even murkier. SSRIs take a long time to work, and if you try several of them that's going to take months to years.

Better months than the rest of my life.

Presented like a true graduate of the Facebook School of Medicine and Immunology.

I'm quite a difficult skeptic, and I have to admit it's difficult to make a difference between melancholy and mild depression, especially after all those years spent being mildly depressed.

Even if I hate the bootstrap argument, it still has an effect on me, despite my skepticism.

In the end, depression alters my perception of what is really good for my mental health. It's very common that patients are difficult to treat, not only because they might disagree with the diagnostic, but because they can't really understand or perceive their emotions and subtle state of mind. Depression is a bit like obesity, you go back to the cause without caring for the consequences.

I become a bit confused when my psychiatrist lets me choose if I want to keep taking those meds, instead of clearly telling me i should take them. But in my experience, those meds are good for me, even if they're not perfect.

Maybe I will stop then one day, and see what happens, but it might hurt more than I think it will.

Maybe if antidepressants weren't pushed so hard by big pharma, people would respect their use more.

If I may,

it's like the recent trend to call everything rape and sexual assault. At some point I have to start naturally doubting the claim on its face. That doesn't imply I think these things don't happen, just that I don't think someone making a stupid dad joke should turn into the woman shouting sexual assault and I find myself questioning all accusations as a result.

---

I have no opinions on any specific person taking antidepressants, but it's not unreasonable for people to get weary when you can't throw a stick without hitting someone who has been diagnosed with something that's being medicated with antidepressants.

I can tell this thread is going to be a nightmare but whatever I really want to share my experience in case there are people similar to me that need to hear this: I cannot emphasise enough how much Escitalopram (lexapro) has helped me with issues I didn't even know I had until I started taking it. At which point I realised I was living in a constant state of anxiety up to that point, and I probably should have been on it a long time ago, but I never ever thought I reached the criteria for being "medicated" so fwiw I think it's also possible to underrate your own feelings and think you don't need them when you do.

Me too! I used to be anxious about everything going on in my life. When I started Lexapro and it finally started working, I realized, "Wow, is that what normalcy feels like?" It's been a lifesaver.

I also used to have general, ever present anxiety, but never was medicated for it. It seems to have abated by around age 29 to a large extent.

One thing that helped was finding a group of friends who loved and accepted me as I was. Really a key moment in dealing with the social component of anxiety.

I think pharmaceutical intervention and my path are both valid, but it's way harder to prescribe "friends who love you in the right way."

Oh trust, my friends are amazing and great. But doesn't stop the always present anxiety of everything collapsing and going wrong. Worked on some CBT to also help me manage it, but medicine has been a really great solution for me, in my opinion. And honestly, I feel like my anxiety has gotten worse as I've aged, I wasn't anxious at all like this in college and I'm now 30.

So we're the drugs able to help you get past the anxiety enough to figure out what the root was or assist in CBT? I always fear that psych drugs are used to mask the root cause.

So glad to hear that ♥ it's such a strange feeling that is really hard to describe

Same here! I was like “wow, this is what it’s like to not be so cynical and defensive and anxious all the time!”

I lived like that for 15 years :(

so happy for you ♥ and yeah such a weird feeling, reading this thread it seems like a real problem and i'm not exactly sure what the solution is, but I think unless other people are noticing that you are extremely anxious and are specifically recommending you see a doctor, I'm not sure it's possible to notice yourself unless you are in the habit of taking dsm tests for fun, and even then I'm not sure that would work b/c some of the questions are "how often do you get anxious" which presumes you know what the feeling of anxiety is vs the feeling of "not-anxiety"

Agree. I have watched a family member suffer mental health, anxiety issues. When she turned 18 she was finally able to get the doctor to prescribe meds. It was a life-changer for her.

So chalk that up as another Lexapro win (that was not forced by some drug company on the patient).

That's exactly what happened to me. I began to take it when the pandemic hit and latter decided to stop. But it was transformative in the sense that it made me aware of how handicapping my anxiety was. My doctor didn't want me to stop tho. I clearly match the criteria to stop (stable for an year), while he still recommended that I continued. He didn't veto my stopping either, but it was my decision.

SO glad to hear that ♥ how do you feel now that you're off it

I feel challenged, but capable. My body has been anxious, but I have been able to deal with daily life quite effectively.

Awesome, congrats! I don't really have an offramp planned rn but will probably start thinking about one at some point.

Adding to the anecdata, on the other hand, when I took it, I just felt the same :(.

Sorry to hear that :(

Just another +1. Also for me the "activation dose" was 15mg, and I spent almost a year taking 10mg a day thinking it didn't work, before moving to 15mg and my life changed.

For anyone else with anxiety issues, silexan[0] and l-theanine[1] are cheap and worth a look-in

0: https://astralcodexten.substack.com/p/lavenders-game-silexan... 1: https://examine.com/supplements/theanine/

wow yeah I also had a very specific activation dose which was 20mg, although I definitely did feel better on the lower doses too, but something definitely happened after 20mg where things felt black and white different

I use this too, a very low dose to just alleviate my anxiety. If I don't take it, stress often leads to severe anxiety for me. The same way it leads to ulcers or other things for other people.

A small dose of it serves as a safety net for me. I still get it but it doesn't get out of control.

I've tried to do without in the past but eventually when I get in a rough patch things get bad and this drug is only affective after taking it for a few months. So just taking it when it's most needed is not an option.

I know someone who insists that her life was saved by escitalopram. However, please be aware that SSRIs are not necessarily free to try, physiologically nor socially speaking. I tried it at the recommendation of my doctor for anxiety. It did not help, and the side effects (lack of empathy, weight gain despite loss of appetite, and others) worsened my situation and strained friendships.

However, my real issues began when I tried to _stop_ taking it. I've experienced opiate withdrawal from pain medication, which was enough to make me sympathetic toward heroin addicts, but SSRI withdrawal was by far the worst I've ever experienced. I used SSRIs for 3 months, but it took 6+ months to wean myself off of them due to debilitating "brain zaps". I got the lowest dosage pills and shaved them onto a milligram scale. I crushed them and dissolved them into a titration solution so that i could wean myself more slowly. I read about psychiatrist claims that SSRI withdrawal "brain zaps", which, it turns out, are known to affect some people, are benign because they "only last a fraction of a second". That may be true for a single zap, but when they occur once every five, ten, or twenty seconds, it's a different story. When these "zaps" occurred, not only was it disorienting, but it felt like I missed half a second of time, and when they got bad, a substantial brain fog set in. They destroyed my focus, and i couldn't get much work done. Driving became dangerous: I would simply miss the existence of entire cars, and I had a few close calls before I realized what was going on and refused to drive any longer while in that state. Weaning more slowly would keep the zaps at bay, but once they began on a given day, it was too late, and my day was over: taking more escitalopram at that point would help, but only gradually over the course of the day.

My withdrawal reaction isn't shared by most, but from my research, it also isn't so rare. I fully recognize that SSRI meds help many people, but be wary about trying them "just to see if it helps," and be aware that once your body gets accustomed to them, coming off of them may not be the experience that your doctor described.

I had those. They were weird. I also didn't taper so there's that.

I'm a bit nervous about these articles clearly centred on the USA which seems to have an epidemic of private drug companies pushing all kinds of stuff via doctors who may or may not be getting backhanders to push certian drugs.

I'm not saying this isn't partially true in Europe but the USA definitely comes across as choosing drugs as the first resort for many things that you wouldn't in Europe.

Also, as many have found out, Prozac is cheaper than therapy or CBT which is what some people might benefit from to actually help them resolve the vicious circle of depression.

Sadly, while this is more rampant in the US, it happens in other places too.

Here are some OECD stats:

https://en.wikipedia.org/wiki/List_of_countries_by_antidepre...

here is that data with US included: https://www.businessinsider.com/countries-largest-antidepres... (tho i am not sure i would trust BI with anything..)

Certainly seems relevant to quite a few european countries. And even more relevant to developing countries to not follow us in that way..

> pushing all kinds of stuff via doctors

And also pushing directly to the consumer via commercial advertising, which is very unusual.

Not sure which way is right though. Maybe people have a right to know about which drugs are available, unscreened by a doctor who may not have your best interests in mind (for example they have to meet a budget, or they have religious opinions.)

I’ve always thought the fact that there are commercials for cancer drugs is very telling. Surely your oncologist will put you on what’s best, right?

I’ve never had cancer but my experience with plenty of other doctors points the other way, and that they wouldn’t be spending money on those commercials if they didn’t get a return from them.

> Surely your oncologist will put you on what’s best, right?

No - best case scenario is they'll put you on the best that their budget and policy allows them to in your particular region.

https://en.wikipedia.org/wiki/Postcode_lottery

https://www.telegraph.co.uk/news/health/2700686/Healthcare-p...

> I'm a bit nervous about these articles clearly centred on the USA which seems to have an epidemic of private drug companies pushing all kinds of stuff via doctors who may or may not be getting backhanders to push certian drugs.

It's not only in the US, France as an antidepressant epidemic, studies have shown anywhere from 30% to 60% of people taking them don't actually need them. They're prescribed too easily.

Are they a good tools: yes

Do they work: yes

Are they abused: yes

I went through a phase in my life a few years ago where I tried most antidepressants available in my European country. All were prescribed to me at varying doses by a psychiatrist working in our public health system.

Almost every single antidepressant gave me withdrawal symptoms (extremely intense mood swings and brain zaps) when I tried decreasing the dose. I mentioned this to my psychiatrist, who advised me to split the pills in order to slowly decrease the dosage. Even splitting the pills and taking a quarter of a pill less every 2 weeks was giving me withdrawal symptoms. I resorted to carefully dissolving the medication in water and volumetrically dosing to get the right rate of tapering off. This scenario happened to me with both Sertraline and Fluoxetine. The "newer" antidepressants like Escitalopram and Vortioxetine gave me less withdrawal symptoms, but they also had more severe side-effects whilst on the medication. Obviously this is all anecdotal, but my hope is that doctors would put greater emphasis on the possible adverse effects of antidepressants to patients. No other class of medication has been so... rough? for me. Glad to be medication-free now.

Pretty short article, this quote sums it up: "When the results of all trials submitted to America’s medicines regulator between 1979 and 2016 were scrutinised by independent scientists, it turned out that antidepressants had a substantial benefit beyond a placebo effect in only 15% of patients."

It's unclear what paper they refer to, as it is not linked. This article (https://www.ncbi.nlm.nih.gov/books/NBK361016/) has many citations to papers that cover this stuff. I think the important take away is in "Antidepressant drug effects and depression severity: a patient-level meta-analysis" (https://pubmed.ncbi.nlm.nih.gov/20051569/):

"Results: Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.

Conclusions: The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. "

Short version: if your depression is mild, antidepressants may not work better than a placebo (though placebos are not exactly nothing). If it's severe, there is more of a chance it'll really help,

From my personal experience, I can definitely attest to them helping, though they are not by any means a magic bullet.

If you give a single person medical advice, you can be sued for malpractice.

If you propose medical policy for millions, you can be an anonymous staffer at The Economist.

[Needs citations.]

The anonymous "Voice of God" conceit always puts me off The Economist.

It can on one hand be argued antidepressants aren't necessary for anyone. You can argue that and be correct. This is because antidepressants don't actually cure depression, but lessen the symptoms and enable severe depression to be cured through behavioral changes.

It's a line of reasoning that is technically true but really sort of missing the point.

The problem with treating depressed people is to get them to actually do the things that will help them. That can be incredibly difficult without medication.

> The problem with treating depressed people is to get them to actually do the things that will help them. That can be incredibly difficult without medication.

The problem with talking about doing "things that will help them" is that we don't really have a lot of effective clinical interventions. Even the most common interventions (SSRIs, Congnitive Behavioral Therapy, physical exercise, etc.) are not really that effective at treating depression and have little to no effect in large parts of the affected population. That being said, these treatments _do_ work for some people so they should definitely not be dismissed out of hand (although it may in some cases be regression to the mean more than anything else, i.e. if you get better after a while on your own but have undergone treatments of one form or another you may erroneously believe your most recent treatment was effective).

I was about to write that there clearly are huge differences betwween the US and the rest of the world, but it seems some European countries have caught up with the US, especially Iceland, with more than 140 daily doses per 1000 adults [1]. Interestingly Iceland frequently has one of the top positions in the world happiness report [2].

[1] https://en.wikipedia.org/wiki/List_of_countries_by_antidepre...

[2] https://en.wikipedia.org/wiki/World_Happiness_Report#2022_Wo...

Aren't areas near North Pole dealing with more seasonal depression due to lack of light in winter months?

It seems so. I wonder how much can be compensated with Vitamin D supplements or light therapy.

Given that the lack of light can cause depression, it would be more prevalent the further North (or South) you go as the conditions aren't present at the equator. What would be interesting to know is if people who live in the more Northern regions are more resistant to seasonal depressions, compared to some one from Southern Europe or the Middle East.

You could probably swap "antidepressants" for any number of drugs and it's still a true statement.

Correct, and also, antidepressants are used for more reasons that to remedy depression (though that may well be their primary purpose). E.g. I use them to combat GAD, though it stems from ASD.

I think antidepressants are getting the spotlight because some (many) were approved with only a slim <10% improvement over a placebo... I think the same could be said about the congestion medication phenylephrine [1] (edit: added specific drug name. edit 2: added link)

I get the feeling that drug approval laxed for a good while and let these slip through

[1] https://pubmed.ncbi.nlm.nih.gov/17264159/

I'm not sure how universal this is, but for me, phenylephrine is literally just side effects. It still makes my anxiety worse, but does nothing for my congestion.

Without knowing the exact approval history in the US, I doubt that it is a lax approval process as much as it is an absence of better alternatives.

There are not really any known effective clinical interventions (be they in the form of medicine, therapy, or things like more exercise), and a 10% improvement is better than nothing (clinical therapy (notably Cognitive Behavioral Therapy) is generally believed to be more effective but not by that much and it is financially out of reach for many people who are able to afford medication).

More on this from Derek Lowe of Things I Won’t Work With fame:

https://www.science.org/content/blog-post/uselessness-phenyl...

For most other drugs the effectiveness is openly disclosed to patents. Also most other drugs have fewer, rarer, less severe side effects. And most other drugs can be stopped and started much more easily...

I find it interesting that the article doesn’t describe a single harm from the drugs, instead focusing on alleged weak efficacy.

My theory is that the article is playing into a vaguely Protestant ethos that drugs are Bad and Unnatural and thus suspect, and (implicitly) that suffering is actually good to some extent and that alleviating it through “artificial” means is unnatural. This attitude is ubiquitous in the US and I assume UK (where Economist originates) as well. Even artificial sweeteners are ridiculously scrutinized and suspect for the same reason.

If some or even many people are taking what the article calls “useless” drugs, how is that, absent serious side effects, bad?

Article seems to be a bit short on numbers in general, and surely this is a complex topic, but this part stood out to me:

> Doctors rarely talk to patients about stopping the drugs because they fear this could lead to a return of depressive symptoms. But for many people it may be safe to stop. Even among long-term users with several past episodes of depression, a recent trial in Britain showed that 44% of patients could stop taking pills safely.

Those don't exactly seem like hugely encouraging numbers.

What this suggests to me is that what we diagnose as "depression" has multiple causes, and current antidepressants are fairly effective at treating at least one of them.

It's as if we had a single category for "breathing trouble" and consistently treated it with antibiotics. Sometimes it's bacterial pneumonia and that works very well. Often it's emphysema or lung cancer, and antibiotics don't help.

I’ve never been on antidepressants but I had a period in my life where I went through a long depression. Inevitably I came to accept I was depressed because my body was telling me something in my life just wasn’t right, and I suspected what it was but didn’t really make an effort to do something about it. Once I made necessary changes things started getting better with time and eventually I got back to normal. However, if I had been on meds I doubt I would have had this sort of introspection and probably would not have bothered changing anything as long as I felt good. I think a lot of people are resistant to real change and antidepressants just help them cope indefinitely.

Prescription of antidepressants really should be coupled with therapy (and often is), which if done right should prompt plenty of introspection. Also in those with severe depression, functioning is so low it can be difficult to even engage in therapy or make life changes without other treatment first.

I think you make an interesting broader point though. Clinically there is not enough consideration of life circumstances when evaluating depression, in my opinion. Obviously something like a death in the family is taken into account, but from what I've seen baseline quality of life is not a huge consideration in whether depressive symptoms are clinically meaningful. I suspect antidepressants would be more effective if this were better teased out.

In any event, there are certainly interesting philosophical and policy questions here, but for an individual that suspects depression, they should seek professional help regardless. A good clinician is not going to just prescribe meds and then tell the patient they're done.

I view overcoming depression similar to weight loss. A lot of people will try hard on their own or with the help of someone else to achieve it, but at the end of the day it’d be far easier to shove a pill down someone’s throat rather than convince them to change their lifestyle and values, simply because most people will try and fail anyway. With the right mindset, I think you could overcome any depression naturally if you are willing to really reconfigure your life and can endure the change. The deeper in it you are, the harder it will be of course, but I think it’s possible.

I mean there also are people that have genetic conditions which make it almost impossible to not be obese without external intervention. Those people are obviously a minority of the obese population, but I wouldn't say that anyone can overcome naturally.

I also don't think it is inherently wrong to include medication (or in the case of obesity, surgery) as part of an intervention in conjunction with lifestyle changes. If done correctly such interventions can be better than the sum of their parts.

It's unfortunate that there are so many bad clinicians out there, but that doesn't mean we should let it affect our opinion on actual best practices. There's a difference between putting in a reasonable amount of work and unnecessarily struggling (although admittedly that's sometimes a fine line).

I think we'll look back to this era the same way we currently look back at the time we prescribed heroin for all kinds of things: https://upload.wikimedia.org/wikipedia/commons/3/38/Drug_sto...

The fact that they work and helped people isn't mutually exclusive with the fact that they're abused, over prescribed and have crazy side effects

It's interesting to see comments like this gain traction in reference to anti-depressants, but get heavily criticized when they are pointed at ADHD meds.

I’m someone who has dealt with mental health issues over the course of my life.

The main causes are the following:

1) Illicit drug use. 2) Stress/anxiety/fear/grief

The answer is to accept the hard truths and understand what is the root cause of your depression. Is it lack of friends and family? Lack of hope for the future? Lack of enjoyment in things that previously made you happy? Belief that somehow success/truth comes at the expense of enjoyment of life (“ignorance is bliss”). Is it past trauma? A job/relationship you hate? Body/health issues? Aging? Feeling like you’ve achieved all your dreams but you’re more unhappy than ever? Bullying? Feeling unsatisfied? Unfulfilled? Shame about past behaviors?

All of these problems have solutions. Figure out what is at the core of your problem, and then treat it. Every problem is different.

For me, I realized I was harboring an incredible amount of pent up rage and resentment. The rage was so deep that it was all I could think about. Then I realized, I had to forgive the people who’d wronged me. And forgive them I did. I genuinely forgave them, in my own mind. And just like that, all my happiness came back to me. Suddenly I was free.

Also, I believe that almost all of our problems can be traced back to fear. So stop worrying. It’s a waste of energy.

There are some mental health issues that do require hospitalization and a short stint of medication to get people back on their feet and able to function. But I don’t believe in long term medication. Drugs are not the answer.

>The answer is to accept the hard truths and understand what is the root cause of your depression. Is it lack of friends and family? Lack of hope for the future? Lack of enjoyment in things that previously made you happy? Belief that somehow success/truth comes at the expense of enjoyment of life (“ignorance is bliss”). Is it past trauma? A job/relationship you hate? Body/health issues? Aging? Feeling like you’ve achieved all your dreams but you’re more unhappy than ever? Bullying? Feeling unsatisfied? Unfulfilled? Shame about past behaviors?

some of these things (body/health issues, bad job/relationship, lack of friends) are causes which can be fixed with direct action. Some (aging, past behaviors, trauma, lack of family) can't be, but can be somewhat mitigated and be made less depressing with therapy. Others (lack of hope, anhedonia, lack of fulfillment) are not the cause of depression but the symptoms. to lump these all together seems strange to me.

Hopelessness and unfulfillment might be considered symptoms of depression if you think that depression is caused by a chemical imbalance. But if hopelessness and unfulfillment create an emotional response by imbalancing chemicals, then the depression is the symptom.

I can't see how hopelessness and unfulfillment would cause you to feel happy, and even feeling neutral seems a stretch. Seems like if you aren't depressed if you are hopeless and unfulfilled then something is wrong! It seems to me like American (Western?) society as a whole is pretty committed to avoiding dealing with hard realities--not just emotions--and we just want to take a "pill" to have it all go away. Anti-depressants have uses, but they aren't the solution any more than meth or pretending the problem doesn't exist or magical thinking are.

I believe those types of problems can be mitigated or even solved by changing your perspective. Example, I can’t get revenge on those people who wronged me. But I can forgive them. And through that, I no longer care. It is in the past, and like children who have stolen a cookie from my jar, I have to forgive them. And so I’m released from my anger.

I’m not sure what the solutions to those other problems are, but I think there would be solutions of a similar vein.

I think SSRIs must be analyzed separately for depression and anxiety disorders.

SSRIs are only marginally better than a placebo for depression. But they are incredibly beneficial for panic disorders and GAD (a bit anecdotal). Still, they will not "get rid of" panic disorders and GAD; only CBT or other therapies can do that. But SSRIs should not be dismissed easily for anxiety disorders, especially if the alternative is using Xanax or recreational drugs (including alcohol).

Try Vitamin B1 as antidepressant:

Cheap and basically no side effect: https://pubmed.ncbi.nlm.nih.gov/26984349/

Especially some B1 analogues like Benfotiamine and Sulbutiamine are promising: https://nootropicsexpert.com/sulbutiamine/ https://en.wikipedia.org/wiki/Vitamin_B1_analogues

What these articles seem to ignore is that depression is only one disorder they're approved to treat. They're approved for GAD, OCD, and a host of other anxiety related disorders.

I do note that everyone (including myself) who's promoting Lexapro on this thread is talking about the positive effects it had on their anxiety

I have these friends. Husband and wife. Rich. Academic. Political. Both on antidepressants.

They get a dog. Beautiful white german shepherd.

Dog is a bit wild. So they consult a "dog psychiatrist".

Psychiatrist puts dog on antidepressants.

Why not a few weeks of Doggy Dicipline Academy? It's common to get german shepherds a bit of training.

"Nope" says the psychiatrist. "That would be cruel".

They worship that psychiatrist. Dingalings.

Dangerous title for this article and I am not sure I like it.

That being said I personally think lack of exercise and desk jobs are having a very big negative effect on mental health in general.

For anyone that has owned a dog - especially a larger high energy dog - what happens when you keep that dog inside all day and do not take it on walks or let it run? What if you then also provided it with all of its favourite food and plenty of fun dog TV shows and games and stimuli but still forced it to sit in a 500 sq ft box all the time? The dog would go nuts - anyone who has owned one knows this - they become an anxious mess. Some of them become self destructive, some of them become neurotic and repeat weird behaviours, and some just sit there and look sad. Are we really all that different than dogs?

It's not clear that I need mine either. But whenever I try to get off my medication (Effexor), I just can't: with a month, I am having debilitating anxiety and suicidal thoughts. I have to live with horrible side effects for the rest of my life.

Maybe the Economist should try staying in their lane? From some of their recent articles I'd say they struggle enough with finance and the economy.

This article approaches the drugs for being used to treat depression. I am on 2 anti depressants and not because I have depression. I take Fluoxetine in the morning to help with my foggy head due to fibromyalgia. I then take Amitriptyline in the evening to help with chronic pain so I can get to sleep.

A lot of drugs are licensed to treat X but doctors will use them to treat Y.

Having read Brave New World again as an adult, I found it to be quite related to this theme.

https://archive.ph/kvVIf

I've taken Prozac zoloft mirtazapine Cymbalta, and wellbutrin, probably a few more I can't remember.

They all made me incredibly anxious, like I could jump off a building. I dknt know why.

I'm about to schedule with a psychiatrist for Lexapro, wish me luck.

Not only are news articles like this terribly ignorant they are dangerous.

I'm all for freedom of speech, but when your speech hurts people there need to be consequences.

I view depression as the result of a faulty process. It seems to me that it's mistake to take a drug to correct these symptoms, rather than learning to control one's thoughts and perspectives.

SSRI's don't remedy depression. They regulate depression related anxiety. They do not cure deptession, just mitigate a sympton.

"Dreamland" by Sam Quinones has everything you need in the subject. Terrific read, top 10 IMHO.

Anecdotally I don't know a single person with solid life habits (exercise, meditation, social interaction, belief and practice with God, engagement with nature) that are on anti-depressants. I kicked the habit myself some years ago and haven't looked back.

In comparison, everyone I know on antidepressants are massively deficient in certain areas and refuse to work on them.

The number of shills and bots for big pharma on this thread are saddening.

If you want to see the real horrors of these drugs check out https://ssristories.org/ ...

Weird take, they genuinely work for 15% of people, it says so right in the article. Me included.

Who needs or doesn't need antidepressants is a conversation that should be had between a doctor and their patient and is frankly none of the business of the economist.

Most people on coffee do not need it.

“Buy things you don't need with money you don't have to impress people you don't like”

It's people like you who keep the world turning.

(We detached this comment from https://news.ycombinator.com/item?id=33272853)

Maybe don't take medical advice from an Economics e-zine.

The first question has always been the same:

What does the pharmaceutical industry need?

Open door, meet obvious. Obvious, meet open door.

Like it or not, you are your neurology. You are your synaptic structure, you are your neurotransmitters.

This trick of conscious self awareness doesn't trump neurology.

You can't meditate out of physical systems malfunctioning any more than you can meditate away a broken leg.

These drugs are like casts for broken bones. Just because you can't see the broken system doesn't make it less physical.

Get a cast. Heal the anatomy. Try and walk again.

>Like it or not, you are your neurology. You are your synaptic structure, you are your neurotransmitters.

Yeah, but look who's saying that. Your neurology etc.

By that logic the cast of Seinfeld is a tribe of gnomes living inside your tv.

Not really, I'm just saying you are your neurons and their configuration and function.

If not, what are "you"? There's nothing else but the state and mechanics in your brain and their interface with the world.

I appreciate for some, this fact is scary. For some, it undermines odd outdated ideas of soul or spirit. That doesn't make it less true.

Sometimes this complex, organic, non-deterministic, environment coupled, feedback driven system ... gets out of balance and needs help.

You are merely reiterating your argument, with an accusation of fear and religion on top.

Your comments were not a rebuttal of mine, just a vague "doesn't sound right to me".

So ..

> If not, what are "you"? There's nothing else but the state and mechanics in your brain and their interface with the world.

I would say that’s only probably correct. Plenty of people would say you are completely wrong. I’m undecided, personally.

Yeah neurology definitely doesn't drive your entire experience of reality. That's why you can remove the brain from the body and the person still lives and functions as if nothing happened.

> These drugs are like casts for broken bones. Just because you can't see the broken system doesn't make it less physical.

They're absolutely not like this. In fact, doctors themselves will tell you we aren't 100% sure how or why they work, and so will a Psychology 101 class. That's why medication is generally given in conjunction with counseling/therapy.

You can be unsure of exactly how they work, but be able to verify that they do (unsure in a scientific sense can still be quite sure. MRI imaging to verify is hard.).

The cast analogy of a "supporting treatment" stands.

I mean, the fact the comments here exist on a forum primarily concerned with engineering is astounding.

Medication is given with counselling and therapy because that too can enact change on neurochemisty through self direction when the system isn't in functional collapse.

For a broken leg you might have metal pins and physio. For a broken leg we wouldn't be having these odd discussions, and the brain is fair more complex.

Maybe everyone should stop taking psych 101 and counting themselves experts in neurochemistry and neuropsychiatry then dishing out poor advice.

Admittedly the US health care system is broken by perverse incentives and so on, but let's not turn that into an attack on the science and efficacy of the drugs themselves for many people.

It freaks me out that most people do not realize this, and instead think that consciousness is some sort of magical or metaphysical process.

It's really dangerous because it implies that psychological illnesses are not "real" like other non-psychological illnesses are. This causes people to believe weird things, like that you can just will yourself out of a certain state, or that these illnesses are caused by laziness, and in some cases think they are just totally fake.

Like you said, all of your psychology, your consciousness, emotions, sensations, etc are physical reactions happening inside of your brain and nervous system, there is no nonphysical aspect to any of it. All of it is just a bunch of "circuits" inside of your brain tissues and various nerves in the body.

This isn't even a debatable issue unless you believe in some sort of magic nonphysical thing that exists outside of the 3d space we reside in. Nonphysical things by definition do not make any sense.

This applies to more than just consciousness too, the same basic idea applies to "spirits" for example. When you cut someone open you don't find a spirit inside of them, it's just a bunch of physical organs and tissues.

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