7 ms·

Depression Confessional Culture Obscures the True Nature of Mental Illness

69 points by empressplay 12y ago

formulaT 12y ago
I'm glad that someone is challenging what the author calls the 'medical "physical" theory of depression/anxiety', although it's unfortunate that the only way to do this is to use another progressive narrative (alienation caused by capitalism). To me, the biggest gap in the mainstream theory is that it claims that depression is qualitatively different from sadness, and yet I have never seen any scientific article that provides evidence of this. The usual argument that is given for this distinction is that, unlike merely being sad, depression produces extreme feelings of helplessness, pessimism and inability to act. And yet what if these were actually just extreme versions of things that already go along with what we call sadness? That is, what if mild sadness and mild depression were the same thing, and severe depression was categorically different from mild sadness only because it was more extreme?
- lolo_ 12y ago
  Having suffered from severe depression I sincerely doubt your analysis. There are times where you feel deeply numb and no sense of sadness whatsoever. You'd have to bend over backwards to call that an extended version of sadness, where it somehow eliminates its own emotional experience. Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for.
  - formulaT 12y ago
    I disagree that because depression has these qualities that it cannot be thought of as extreme sadness. I think that human experience and emotions are complex, and that for various reasons, extremes of unhappiness may result in these symptoms. >Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for. On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness. I don't see any logical connection between the views that(1) severe depression is a serious problem, and (2) severe depression is on a spectrum where the milder versions are not distinguishable from being unhappy or "in a rut". [0] http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml http://www.nimh.nih.gov/health/statistics/prevalence/major-d...
    - darawk 12y ago
      I think the author of this article's point, and the point that is most likely accurate is that depression is sometimes a manifestation of a physical malady and sometimes not (of course the lines between physiology and psychology are becoming increasingly blurry). The take-away here is not really whether the condition is or is not physical, but rather, what the labeling of it as physical does to the perspective of its sufferers and its effect on their prognosis. Pyschological issues of this nature are a curious form of disease, in that the mental models of their sufferers form a feedback loop with the condition itself. Whether or not depression is physical, thinking that depression is physical has a tangible effect on the condition itself, one that this author and I would argue is sometimes (though not always!) negative. However, it is in the interest of pharmaceutical companies that it be thought of as purely physical, with purely physical treatments. And it can be argued that this mode of treatment, and this mental model in the minds of the sufferers is self-reinforcing. Because it is presented as a physiological ill, depressed persons see it as such, and eschew or don't fully invest themselves in alternative solutions, which make them not work. The sum of all of this is that depression is one of the few diseases that is actually itself shaped by the marketing of its treatments. Which is both interesting and troubling, given the relative inability of the current regulatory framework to cope with this systemic condition.
      - DanBC 12y ago
        See also chronic fatigue, where people reject entirely any psychological help. And if someone's CFS is treated, cured, by a psychological treatment, well, they were faking it. (This has pretty much been said on HN before.)
    - lolo_ 12y ago
      >I disagree that because depression has these qualities that it cannot be thought of as extreme sadness. I think that human experience and emotions are complex, and that for various reasons, extremes of unhappiness may result in these symptoms. Is this even meaningful? What you're saying is 'emotions are complex so feeling X might just be a more extreme version of Y even though it sometimes shares no properties with Y whatsoever' - doesn't that mean I can now say any experience is just an extreme version of any other? Schizophrenia is really a lot like extreme happiness! You have any problem with that? >On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness. I didn't say put them in 'special categories' (most of the 'mainstream' attitude I experience is that I'm full of shit and should pull myself together, by the way), I said be careful and don't just speculate as if it were a folly in a public place like this, since you risk coming off like you're downplaying it. You can categorise however you like, but _back it up_ and have a little compassion. This isn't a programming language pissing match. Saying severe depression is a more extreme sadness potentially implies you should do some lovely happy nice things to fix it like you can with milder sadness - much like the usual bullshit I hear about how if only I did more exercise it'd all be fixed and really you can fix it if you just put some effort in! Never mind that the lead PT of the biggest fitness brand in the UK jumped off a cliff, or that many people with seemingly great lives have committed suicide... Saying something is just more of something else, implies that usual fixes apply, just you need to do more. I'm not saying you think any of this, but that you need to tread carefully - these are actually I think (and experience) most people's views anyway, even if they don't want to say it, so both for depressives and those who might interact with them, you're potentially doing harm - is you waxing philosophical of more value than that potential harm?
- speechduh 12y ago
  As you yourself said, the claim is "qualitatively" different, not "quantitatively" different. If you think about what qualitatively means, I really have no idea what you're trying to say. "Just" being "more extreme" is sufficient for something to be qualitatively different. Different symptoms start manifesting, especially as compensatory systems start to fail. As far as I can tell your point is vacuous; please clarify, otherwise. If you're instead trying to say that they're biologically / mechanically similar phenomena, well, that's a different discussion we could have. Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful. I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point.
  - formulaT 12y ago
    The main point is that there are a number of different axes along which "severe", "major" or "clinical" depression is said to differ from ordinary sadness, and that the qualitative distinction is used to justify all of these. The main ones are 1) Depression (unlike sadness) is not caused by circumstances that cause a person to be unhappy. 2) Depression (unlike sadness) can only be cured by addressing to root (medical) cause of unbalanced brain chemistry. 3) Depression (unlike sadness) either is not curable, only the symptoms can be cured, or people who recover are prone to relapse. >Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful. No, but maybe I've experienced things just as bad? I don't really know, but I also don't know how you claim to be able to compare your experience to mine. I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point. It's a logical fallacy to think that people do/should only make arguments with some end goal. My goal is to express my opinion on the nature of mental illness. Another fallacy is that arguing that "X is true" can be immoral, because of X were true, then some immoral consequence would follow. If I am right, we should still be just as compassionate towards other people's problems. You can be compassionate and understanding towards someone's problems without categorizing those problems as a medical illness. Similarly, you can use this categorization as an excuse not to be compassionate, e.g. treating a person as irrational or untrustworthy because they have had a mental illness in the past.
- magnifyingglass 12y ago
  Even if a scientist can legitimately prove depression is different from sadness, you will not believe it, because it requires a degree of subjectivity you will not tolerate. You expect a kind of purity, an objective, emotionless vocabulary with it's associated numeric data; data that has been wiped clean of the people and the lives of those people it describes, to describe that which is fundamentally indescribable to someone who has never experienced it. Sometimes compassion means saying 'okay, I understand, that sucks?'.
- DanBC 12y ago
  > I'm glad that someone is challenging what the author calls the 'medical "physical" theory of depression/anxiety', What? Mainstream firstline treatment for depression is a talking therapy. This rejection of the physical basis is written into government provided guidance (see eg UK NHS guidance for depression and anxiety).
- shredprez 12y ago
  I've been reading through your responses and agree generally with your perspective on this issue (I say this as someone who has dealt with varying levels of depression behaviorally and chemically, both on my own and with professional assistance). But I'm curious about your fundamental position on the "physical theory", which seems to imply there's a real distinction between physical processes and emotional processes, and that sadness, extreme or not, is non-physical. Sadness is not some ephemeral phantasm that floats beyond the body. It's a cognitive/neurological response to external stimuli. It's a biological event. My personal opinion is that controlling your brain with chemicals should be a last resort, because in many cases you can achieve similar results with relative consistency by addressing underlying social problems. While more labor-intensive, achieving satisfaction without drugs is liberating. But I don't think normal emotions are categorically distinct from medicalized emotional states: both are chemical or electrical processes. It seems you disagree. Am I misinterpreting your position?
  - formulaT 12y ago
    I used the term physical as a quote from the author, who also used in quotes (hence the python style quotes in my post). But "physical" somewhat captures the medical view on depression, as something distinct from the ordinary spectrum of "healthy" emotions, and with causes that are primarily internal not external (although, as you say, all thoughts and emotions are ultimately mediated through physical processes in the brain). So my point wasn't that sadness is non-physical, but rather all experiences are physical, and most experiences belong to the spectrum of human emotions, which are influenced by external and social events, thought not always in the most obvious way (hence my opposition to the "just get over it" strawman, since "just get over it" might be a bad response to mere sadness too). I also don't have a strong opinion on chemical intervention, except that I would hold them to a higher standard of evidence since I have a stronger prior on the root cause being social and emotional, rather than a congenital inbalance in brain chemistry. It's plausible that they work, and if they work, they should be used.
spenrose 12y ago
An excellent book on depression, arguing it is an evolved capacity of the mind: http://psychcentral.com/lib/the-depths-the-evolutionary-origins-of-the-depression-epidemic/00018693 "Overall, this is a surprisingly accessible book and one that would serve any layperson well as an introduction to the science of depression. Rottenberg’s practical style and talent for using real-world examples by real-world people to illustrate states of low and high mood is refreshing. While not an in-depth tome by any means on depression, treatment, or evolutionary origin, the book is a wonderful first step for those who wish to better understand the illness from a scientific viewpoint. And it gives the reader hope by suggesting that depression is a common, albeit painful, human experience: that a low mood does not mean we have failed."
ta-026d16b2 12y ago
While it raises a few valid points, this essay is pretty bad overall. Apart from distorting the history of SSRIs (one can't meaningfully tell the story of the rise of SSRIs without talking about the prior successes and drawbacks of tricyclic antidepressants and MAO inhibitors), it pushes a false narrative characteristic of politically-motivated drug-bashers: there is a single "physical theory" of depression, centered on two or three molecules, that was advanced through commercially-motivated distortion of science and later debunked. The basic monoamine hypothesis has been known to be faulty for decades, nearly as long as monoamine reuptake inhibitors have been in widespread use; the psychiatric research community has long since been studying other possibilities. Studies do show that, on average, antidepressants barely outperform placebo. However, this is because the effects of antidepressants are correlated to symptom severity, so averaging the entire population together shows virtually no difference. This certainly supports less widespread use of antidepressants than has been common in recent decades, but not that antidepressants are useless. It's not like the evidence generally shows that psychotherapy is much better, either. It's prescribed so much less not out of some ideological antipathy for introspection and hard work, but because it's not generally any more effective, costs far more, has much worse compliance, and is less readily available (especially in smaller cities and rural areas) than generic drugs. The dirty little secret of psychiatry isn't that SSRIs don't work; it's that everything sort of works, but any single thing doesn't work very well for most patients, and there's no validated model that predicts which treatment is likely to work for which patient. In my opinion, the biggest problem with studying depression is that the diagnosis of depressive disorders is tremendously unreliable. Virtually all of their symptoms overlap with "sickness behavior", which is triggered by dozens (if not hundreds) of different physiological diseases. Implicit in the diagnosis of a mood disorder (actually explicit in the DSM, but people are rarely told this) is that those diseases have been ruled out as the underlying cause. In practice, this rarely happens. Doctors will do some perfunctory screening for things like hypothyroid and hypogonadal disorders, but those screening tests have very poor sensitivity and only cover a handful of common causes of depressive symptoms. If you're lucky, you might get an actual formal screening for neurological disorders. Initial screening for sleep disorders is mostly done with crappy questionnaire scales that disproportionately focus on superficial aspects of stereotypical presentation ("Do you snore?"). In a nutshell, being diagnosed with a depressive disorder has little inherent meaning beyond your GP/PCP running out of ideas or patience. In turn, any given study population of "people with depressive disorders" is unlikely to actually be homogeneous in the origins of its depressive symptoms.

69 points by empressplay 12y ago

I'm glad that someone is challenging what the author calls the 'medical "physical" theory of depression/anxiety', although it's unfortunate that the only way to do this is to use another progressive narrative (alienation caused by capitalism). To me, the biggest gap in the mainstream theory is that it claims that depression is qualitatively different from sadness, and yet I have never seen any scientific article that provides evidence of this. The usual argument that is given for this distinction is that, unlike merely being sad, depression produces extreme feelings of helplessness, pessimism and inability to act. And yet what if these were actually just extreme versions of things that already go along with what we call sadness? That is, what if mild sadness and mild depression were the same thing, and severe depression was categorically different from mild sadness only because it was more extreme?

lolo_ 12y ago
Having suffered from severe depression I sincerely doubt your analysis. There are times where you feel deeply numb and no sense of sadness whatsoever. You'd have to bend over backwards to call that an extended version of sadness, where it somehow eliminates its own emotional experience. Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for.
- formulaT 12y ago
  I disagree that because depression has these qualities that it cannot be thought of as extreme sadness. I think that human experience and emotions are complex, and that for various reasons, extremes of unhappiness may result in these symptoms. >Also I think you should be very careful down this road, even if you don't intend it, it's very very easy to paint it like it's less serious than it is even if you don't intend to. This is something to look at the _evidence_ for. On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness. I don't see any logical connection between the views that(1) severe depression is a serious problem, and (2) severe depression is on a spectrum where the milder versions are not distinguishable from being unhappy or "in a rut". [0] http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml http://www.nimh.nih.gov/health/statistics/prevalence/major-d...
  - darawk 12y ago
    I think the author of this article's point, and the point that is most likely accurate is that depression is sometimes a manifestation of a physical malady and sometimes not (of course the lines between physiology and psychology are becoming increasingly blurry). The take-away here is not really whether the condition is or is not physical, but rather, what the labeling of it as physical does to the perspective of its sufferers and its effect on their prognosis. Pyschological issues of this nature are a curious form of disease, in that the mental models of their sufferers form a feedback loop with the condition itself. Whether or not depression is physical, thinking that depression is physical has a tangible effect on the condition itself, one that this author and I would argue is sometimes (though not always!) negative. However, it is in the interest of pharmaceutical companies that it be thought of as purely physical, with purely physical treatments. And it can be argued that this mode of treatment, and this mental model in the minds of the sufferers is self-reinforcing. Because it is presented as a physiological ill, depressed persons see it as such, and eschew or don't fully invest themselves in alternative solutions, which make them not work. The sum of all of this is that depression is one of the few diseases that is actually itself shaped by the marketing of its treatments. Which is both interesting and troubling, given the relative inability of the current regulatory framework to cope with this systemic condition.
    - DanBC 12y ago
      See also chronic fatigue, where people reject entirely any psychological help. And if someone's CFS is treated, cured, by a psychological treatment, well, they were faking it. (This has pretty much been said on HN before.)
  - lolo_ 12y ago
    >I disagree that because depression has these qualities that it cannot be thought of as extreme sadness. I think that human experience and emotions are complex, and that for various reasons, extremes of unhappiness may result in these symptoms. Is this even meaningful? What you're saying is 'emotions are complex so feeling X might just be a more extreme version of Y even though it sometimes shares no properties with Y whatsoever' - doesn't that mean I can now say any experience is just an extreme version of any other? Schizophrenia is really a lot like extreme happiness! You have any problem with that? >On the contrary, I don't see why we need to put things into special categories in order to respect people's problems and properly judge their seriousness. I didn't say put them in 'special categories' (most of the 'mainstream' attitude I experience is that I'm full of shit and should pull myself together, by the way), I said be careful and don't just speculate as if it were a folly in a public place like this, since you risk coming off like you're downplaying it. You can categorise however you like, but _back it up_ and have a little compassion. This isn't a programming language pissing match. Saying severe depression is a more extreme sadness potentially implies you should do some lovely happy nice things to fix it like you can with milder sadness - much like the usual bullshit I hear about how if only I did more exercise it'd all be fixed and really you can fix it if you just put some effort in! Never mind that the lead PT of the biggest fitness brand in the UK jumped off a cliff, or that many people with seemingly great lives have committed suicide... Saying something is just more of something else, implies that usual fixes apply, just you need to do more. I'm not saying you think any of this, but that you need to tread carefully - these are actually I think (and experience) most people's views anyway, even if they don't want to say it, so both for depressives and those who might interact with them, you're potentially doing harm - is you waxing philosophical of more value than that potential harm?
speechduh 12y ago
As you yourself said, the claim is "qualitatively" different, not "quantitatively" different. If you think about what qualitatively means, I really have no idea what you're trying to say. "Just" being "more extreme" is sufficient for something to be qualitatively different. Different symptoms start manifesting, especially as compensatory systems start to fail. As far as I can tell your point is vacuous; please clarify, otherwise. If you're instead trying to say that they're biologically / mechanically similar phenomena, well, that's a different discussion we could have. Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful. I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point.
- formulaT 12y ago
  The main point is that there are a number of different axes along which "severe", "major" or "clinical" depression is said to differ from ordinary sadness, and that the qualitative distinction is used to justify all of these. The main ones are 1) Depression (unlike sadness) is not caused by circumstances that cause a person to be unhappy. 2) Depression (unlike sadness) can only be cured by addressing to root (medical) cause of unbalanced brain chemistry. 3) Depression (unlike sadness) either is not curable, only the symptoms can be cured, or people who recover are prone to relapse. >Have you ever experienced severe depression (i.e., the type that prevents you from getting out of bed for months or causes you to be hospitalized)? Because it's absolutely fucking awful. No, but maybe I've experienced things just as bad? I don't really know, but I also don't know how you claim to be able to compare your experience to mine. I'd love some clarification of where you're going with this hypothetical, because right now it sounds like you're denying the experience of a whole lot of people in a whole lot of pain, without having much of a point. It's a logical fallacy to think that people do/should only make arguments with some end goal. My goal is to express my opinion on the nature of mental illness. Another fallacy is that arguing that "X is true" can be immoral, because of X were true, then some immoral consequence would follow. If I am right, we should still be just as compassionate towards other people's problems. You can be compassionate and understanding towards someone's problems without categorizing those problems as a medical illness. Similarly, you can use this categorization as an excuse not to be compassionate, e.g. treating a person as irrational or untrustworthy because they have had a mental illness in the past.
magnifyingglass 12y ago
Even if a scientist can legitimately prove depression is different from sadness, you will not believe it, because it requires a degree of subjectivity you will not tolerate. You expect a kind of purity, an objective, emotionless vocabulary with it's associated numeric data; data that has been wiped clean of the people and the lives of those people it describes, to describe that which is fundamentally indescribable to someone who has never experienced it. Sometimes compassion means saying 'okay, I understand, that sucks?'.
DanBC 12y ago
> I'm glad that someone is challenging what the author calls the 'medical "physical" theory of depression/anxiety', What? Mainstream firstline treatment for depression is a talking therapy. This rejection of the physical basis is written into government provided guidance (see eg UK NHS guidance for depression and anxiety).
shredprez 12y ago
I've been reading through your responses and agree generally with your perspective on this issue (I say this as someone who has dealt with varying levels of depression behaviorally and chemically, both on my own and with professional assistance). But I'm curious about your fundamental position on the "physical theory", which seems to imply there's a real distinction between physical processes and emotional processes, and that sadness, extreme or not, is non-physical. Sadness is not some ephemeral phantasm that floats beyond the body. It's a cognitive/neurological response to external stimuli. It's a biological event. My personal opinion is that controlling your brain with chemicals should be a last resort, because in many cases you can achieve similar results with relative consistency by addressing underlying social problems. While more labor-intensive, achieving satisfaction without drugs is liberating. But I don't think normal emotions are categorically distinct from medicalized emotional states: both are chemical or electrical processes. It seems you disagree. Am I misinterpreting your position?
- formulaT 12y ago
  I used the term physical as a quote from the author, who also used in quotes (hence the python style quotes in my post). But "physical" somewhat captures the medical view on depression, as something distinct from the ordinary spectrum of "healthy" emotions, and with causes that are primarily internal not external (although, as you say, all thoughts and emotions are ultimately mediated through physical processes in the brain). So my point wasn't that sadness is non-physical, but rather all experiences are physical, and most experiences belong to the spectrum of human emotions, which are influenced by external and social events, thought not always in the most obvious way (hence my opposition to the "just get over it" strawman, since "just get over it" might be a bad response to mere sadness too). I also don't have a strong opinion on chemical intervention, except that I would hold them to a higher standard of evidence since I have a stronger prior on the root cause being social and emotional, rather than a congenital inbalance in brain chemistry. It's plausible that they work, and if they work, they should be used.

spenrose 12y ago

An excellent book on depression, arguing it is an evolved capacity of the mind: http://psychcentral.com/lib/the-depths-the-evolutionary-origins-of-the-depression-epidemic/00018693 "Overall, this is a surprisingly accessible book and one that would serve any layperson well as an introduction to the science of depression. Rottenberg’s practical style and talent for using real-world examples by real-world people to illustrate states of low and high mood is refreshing. While not an in-depth tome by any means on depression, treatment, or evolutionary origin, the book is a wonderful first step for those who wish to better understand the illness from a scientific viewpoint. And it gives the reader hope by suggesting that depression is a common, albeit painful, human experience: that a low mood does not mean we have failed."

ta-026d16b2 12y ago

While it raises a few valid points, this essay is pretty bad overall. Apart from distorting the history of SSRIs (one can't meaningfully tell the story of the rise of SSRIs without talking about the prior successes and drawbacks of tricyclic antidepressants and MAO inhibitors), it pushes a false narrative characteristic of politically-motivated drug-bashers: there is a single "physical theory" of depression, centered on two or three molecules, that was advanced through commercially-motivated distortion of science and later debunked. The basic monoamine hypothesis has been known to be faulty for decades, nearly as long as monoamine reuptake inhibitors have been in widespread use; the psychiatric research community has long since been studying other possibilities. Studies do show that, on average, antidepressants barely outperform placebo. However, this is because the effects of antidepressants are correlated to symptom severity, so averaging the entire population together shows virtually no difference. This certainly supports less widespread use of antidepressants than has been common in recent decades, but not that antidepressants are useless. It's not like the evidence generally shows that psychotherapy is much better, either. It's prescribed so much less not out of some ideological antipathy for introspection and hard work, but because it's not generally any more effective, costs far more, has much worse compliance, and is less readily available (especially in smaller cities and rural areas) than generic drugs. The dirty little secret of psychiatry isn't that SSRIs don't work; it's that everything sort of works, but any single thing doesn't work very well for most patients, and there's no validated model that predicts which treatment is likely to work for which patient. In my opinion, the biggest problem with studying depression is that the diagnosis of depressive disorders is tremendously unreliable. Virtually all of their symptoms overlap with "sickness behavior", which is triggered by dozens (if not hundreds) of different physiological diseases. Implicit in the diagnosis of a mood disorder (actually explicit in the DSM, but people are rarely told this) is that those diseases have been ruled out as the underlying cause. In practice, this rarely happens. Doctors will do some perfunctory screening for things like hypothyroid and hypogonadal disorders, but those screening tests have very poor sensitivity and only cover a handful of common causes of depressive symptoms. If you're lucky, you might get an actual formal screening for neurological disorders. Initial screening for sleep disorders is mostly done with crappy questionnaire scales that disproportionately focus on superficial aspects of stereotypical presentation ("Do you snore?"). In a nutshell, being diagnosed with a depressive disorder has little inherent meaning beyond your GP/PCP running out of ideas or patience. In turn, any given study population of "people with depressive disorders" is unlikely to actually be homogeneous in the origins of its depressive symptoms.