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Chemical Imbalance

[content note: mental illness. I am still in training and do not understand these issues even as well as a fully-trained psychiatrist, let alone a researcher, so take all the biology and studies in here with a grain of salt until you double-check]

I.

IO9’s new article The Most Popular Antidepressants Are Based On An Outdated Theory jumps on a popular bandwagon of criticizing psychiatry for botching the “chemical imbalance” theory. See for example The New Yorker, BBC, The New York Times, and various books.

(…and also The Myth Of Chemical Imbalance, Debunking The Chemical Imbalance Myth, The Chemical Imbalance Fraud, and Depression Delusion, The Myth Of The Chemical Imbalance, etc)

According to all these sources psychiatry sold the public on antidepressants by claiming depression was just a chemical imbalance (usually fleshed out as “a simple deficiency of serotonin”) and so it was perfectly natural to take extra chemicals to correct it. However, they had no real evidence for this theory except that serotonergic drugs effectively treat depression, which is not very much evidence at all (antibiotics effectively treat pneumonia, but pneumonia isn’t “an antibiotic deficiency”). And now the research is unequivocal that serotonin deficiency is not the cause of depression, and psychiatry has ended up with lots of egg on its face.

This narrative is getting pushed especially hard by the antipsychiatry movement, who frame it as “proof” that psychiatrists are drug company shills who were deceiving the public. The conversation has required a host of rebuttals and counter-rebuttals.

For example here antipsychiatry blog Mad In America attemps to rebut psychiatrist Dr. Ronald Pies, who argues that psychiatrists never pushed the chemical imbalance theory. Pies says that “The ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry,” and cites the American Psychiatric Association’s 2005 statement on the causes of depression:

The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers. We can say that certain inherited dispositions interact with triggering environmental factors. Poverty and stress are well-known to be bad for your health—this is true for mental health and physical health. In fact, the distinction between “mental” illness and “physical” illness can be misleading. Like physical illnesses, mental disorders can have a biological nature. Many physical illnesses can also have a strong emotional component

Mad In America doesn’t accept his claim, and counter-cites two speeches by American Psychiatric Association presidents to prove that they did push the chemical imbalance theory:

In the last decade, neuroscience and psychiatric research has begun to unlock the brain’s secrets. We now know that mental illnesses – such as depression or schizophrenia – are not “moral weaknesses” or “imagined” but real diseases caused by abnormalities of brain structure and imbalances of chemicals in the brain.” – Richard Harding, 2001 APA president

And:

The way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated. And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate. So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion. – Jeffrey Lieberman, 2012 APA President

I have no personal skin in this game. I’ve only been a psychiatrist for two years, which means I started well after the term “chemical imbalance” fell out of fashion. I get to use the excuse favored by young children everywhere: “It was like this when I got here”. But I still feel like the accusations in this case are unfair, and I would like to defend my profession.

I propose that the term “chemical imbalance” hides a sort of bait-and-switch going on between the following two statements:

(A): Depression is complicated, but it seems to involve disruptions to the levels of brain chemicals in some important way

(B): We understand depression perfectly now, it’s just a deficiency of serotonin.

If you equivocate between them, you can prove that psychiatrists were saying (A), and you can prove that (B) is false and stupid, and then it’s sort of like psychiatrists were saying something false and stupid!

But it isn’t too hard to prove that psychiatrists, when they talked about “chemical imbalance”, meant something more like (A). I mean, look at the quotes above by which Mad In America tries to prove psychiatrists guilty of pushing chemical imbalance. Both sound more like (A) than (B). Neither mentions serotonin by name. Both talk about the chemical aspect as part of a larger picture: Harding in the context of abnormalities in brain structure, Lieberman in the context of some external force disrupting neurotransmission. Neither uses the word “serotonin” or “deficiency”. If the antipsychiatry community had quotes of APA officials saying it’s all serotonin deficiency, don’t you think they would have used them?

Further, anyone who said that depression was caused solely by serotonin deficiency wouldn’t just be failing as a scientist, but also failing as a drug company shill. Pfizer spent billions of dollars on Effexor, which hits norepinephrine as well as serotonin, and they’re just going to dismiss all of that as useless? GlaxoSmithKline has Wellbutrin, which hits dopamine and norepinephrine and maybe acetylcholine but doesn’t get serotonin at all. So everyone, including the shills, especially the shills, has been very careful to say that depression was a “chemical imbalance” rather than a serotonin deficiency per se.

So if you want to prove that psychiatrists were deluded or deceitful, you’re going to have to disprove not just statement (B) – which never represented a good scientific or clinical consensus – but statement (A). And that’s going to be hard, because as far as I can tell statement (A) still looks pretty plausible.

II.

If you listen to these articles, psychiatrists decided that neurotransmitters (or just serotonin?) were implicated in depression solely on the evidence that SSRIs were effective antidepressants, even though every study trying to measure serotonin levels directly came back with negative results. For example, The Myth Of The Chemical Imbalance Theory writes:

There is no question that the chemical imbalance theory has spurred chemists to invent new anti-depressants, or that these anti-depressants have been shown to work; but proof that low serotonin is to blame for depression – and that boosting serotonin levels is the key to its treatment – has eluded researchers.

For starters, it is impossible to directly measure brain serotonin levels in humans. You can’t sample human brain tissue without also destroying it. A crude work-around involves measuring levels of a serotonin metabolite, 5-HIAA, in cerebrospinal fluid (CSF), which can only be obtained with a spinal tap. A handful of studies from the 1980s found slightly decreased 5-HIAA in the CSF of depressed and suicidal patients, while later studies have produced conflicting results on whether SSRIs lower or raise CSF levels of 5-HIAA. These studies are all circumstantial with regards to actual serotonin levels, though, and the fact remains there is no direct evidence of a chemical imbalance underlying depression.

The corollary to the chemical imbalance theory, which implies that raising brain serotonin levels alleviates depression, has also been hard to prove. As mentioned previously, the serotonin-depleting drug reserpine was itself shown to be an effective anti-depressant in the 1950s, the same decade in which other studies claimed that reserpine caused depression-like symptoms. At the time, few psychiatrists acknowledged these conflicting reports, as the studies muddled a beautiful, though incorrect, theory. Tianeptine is another drug that decreases serotonin levels while also serving as a bona-fide anti-depressant. Tianeptine does just the opposite of SSRIs – it enhances serotonin reuptake. Wellbutrin is a third anti-depressant that doesn’t increase serotonin levels. You get the picture.

If you prefer your data to be derived more accurately, but less relevantly, from rodents, you might consider a recent meta-analysis carried out by researchers led by McMaster University psychologist Paul Andrews. Their investigation revealed that, in rodents, depression was usually associated with elevated serotonin levels. Andrews argues that depression is therefore a disorder of too much serotonin, but the ambiguous truth is that different experiments have shown “activation or blockage of certain serotonin receptors [to improve] or worsen depression symptoms in an unpredictable manner.”

Other problems with the chemical imbalance model of depression have been well documented elsewhere. For instance, if low serotonin levels were responsible for symptoms of depression, it stands to reason that boosting levels of serotonin should alleviate symptoms more or less immediately. In fact, antidepressants can take more than a month to take effect. Clearly, something here just doesn’t add up.

Clearly!

GABA is a neurotransmitter that promotes inhibition and relaxation. Suppose I were to tell you that alcohol is a drug that mimics the effects of GABA. Which it is.

You might say: something is wrong with this theory! After all, people who drink alcohol don’t always get relaxed and inhibited. A lot of the time they get uninhibited and angry and violent! And then if they drink too much of it, they get super-inhibited to the point where they’re in a total blackout. Also, alcoholics who have been drinking for many years have higher levels of anxiety than non-alcoholics, but anxiety is also the opposite of relaxation! Clearly, something here just doesn’t add up. Maybe the neuroscientists are all shills for Budweiser!

Or else maybe the brain is kind of complicated. In the case of alcohol we pretty much know what’s going on. Alcohol does inhibit and relax you, but in some people and at some doses, it preferentially inhibits and relaxes the parts of the brain involved in inhibiting and relaxing the rest of the brain, meaning that the person as a whole because more uninhibited and violent. At higher doses, it inhibits and relaxes the entire brain, leading to confusion and eventually blackout. And once you’ve been taking alcohol for many years, your brain adjusts to the higher level of GABA-like chemicals by producing fewer GABA receptors, making you more anxious.in general. It’s a whole bunch of contradictory effects, but when you look at the neuroscience it makes sense.

We know less about the serotonin picture, but what we know suggests something similar is going on. Serotonin has different effects in lots of different parts of the brain. There are fourteen different types of serotonin receptor, all of which do subtly different things. Some serotonergic neurons have autoreceptors that cause decreased release of serotonin in response to serotonin. The brain responds to different levels of serotonin by slowly altering endogenous serotonin production as well as the expression of the different serotonin receptors. Etc, etc, etc.

Lest it sound like I’m making excuses rather than presenting evidence: A study on a monkey model – generally preferred to humans when you want to kill your patients and take apart their brains when you’re done – showed that depressed macaques had elevated levels of serotonin in the dorsal raphe nuclei and decreased levels of serotonin in the hippocampus, resulting in average levels of serotonin in the cerebrospinal fluid where the experiments mentioned above took their serotonin measurements. A study with a more sophisticated measurement process, Elevated Brain Serotonin Turnover in Patients With Depression, found that depressed subjects had serotonin turnover as measured in the jugular vein about twice as high as healthy controls (p = 0.003), and successful treatment with SSRI therapy corrected this imbalance (though others dispute the methodology).

All of this sort of fits. If depression involves a distorted pattern of serotonin across the brain, then both certain drugs that increase serotonin levels and certain drugs that decrease it might be helpful. And SSRIs might take a month to work if their mechanism of action isn’t the direct serotonin increase, but a contrary response they provoke from the brain. I think I heard from someone in the field that a month is about how long it takes for them to change the levels of expressed 5HT receptors by altering genetic transcription. Or something. I’m not a neuroscientist (though you can read some more complicated work from people who are) and I don’t know. The point is that you can get a heck of a lot more complex than just “Too little serotonin!” versus “Too much serotonin!”

So does this mean depression “was really serotonin after all”?

No. It means we have good evidence serotonin is involved somewhere. Among the other things that we have good evidence are involved somewhere are: dopamine, norepinephrine, acetylcholine, cytokines, BDNF, thyroid hormones, and whether the kids at school picked on you in first grade.

Suppose you ask me what caused you to become blind. I happen to have your medical records and know that the answer is proliferative retinopathy secondary to Type 2 diabetes, but you’ve been living in a cave your entire life and never even heard of diabetes. Which is the correct answer to your question?

1. Your blindness is caused by tiny little blood vessels growing all over your eyes
2. Your blindness is caused by imbalance in a chemical called protein kinase C-delta and the resulting signaling cascade
3. Your blindness is caused by too much sugar in your blood
4. Your blindness is caused by your cells becoming less sensitive to insulin
5. Your blindness is caused by you drinking too much Coca-Cola

All of these are true. You drink too much Coca-Cola, it causes your cells to lose insulin sensitivity, that causes too much sugar in the blood, that increases the activity of PKC-delta, and that causes little blood vessels to grow all over your eyes. Sometimes the chain is different. Maybe you drank too much lemonade instead of too much Coca-Cola. Maybe you drank too much Coca-Cola, but actually instead of causing diabetes it caused hypertension and then you got hypertensive retinopathy which made you blind. Maybe it was diabetic retinopathy, but actually you haven’t gotten to the proliferative stage yet, and you just had a lot of your blood vessels get damaged and start leaking and causing macular oedema. Maybe it was diabetic retinopathy, but you had a perfect diet and lost the genetic lottery. I don’t know.

If someone told you “We think it involves an imbalance in protein kinase” it would be woefully incomplete. But if someone said “That doctor there said your blindness was caused by an imbalance in protein kinase, that proves he’s a fraud!”, well, no, it wouldn’t.

Except the situation is even more complicated than this, because at least I specified this guy had diabetic retinopathy. What if somebody just asked “What causes blindness?” “High protein kinase” or “high blood sugar” would be two answers, and you could find tests supporting both. But “cataracts” would be another good answer. So would “people getting acid thrown in their eyes”.

All I’m saying is that depression is complicated. Discovering its relationship to the serotonin system is a lot like saying “blindness quite often has something to do with the retina”. It’s a big step forward, and don’t believe anyone who says it isn’t, but it’s not anywhere near the whole picture.

III.

And this starts to get into the next important point I want to bring up, which is chemical imbalance is a really broad idea.

Like, some of these articles seem to want to contrast the “discredited” chemical imbalance theory with up-and-coming “more sophisticated” theories based on hippocampal neurogenesis and neuroinflammation. Well, I have bad news for you. Hippocampal neurogenesis is heavily regulated by brain-derived neutrophic factor, a chemical. Neuroinflammation is mediated by cytokines. Which are also chemicals. Do you think depression is caused by stress? The stress hormone cortisol is…a chemical. Do you think it’s entirely genetic? Genes code for proteins – chemicals again. Do you think it’s caused by poor diet? What exactly do you think food is made of?

Diabetes is caused by a chemical imbalance: too much sugar (or too little insulin) in the blood. Parkinson’s is caused by a chemical imbalance: too little dopamine in the basal ganglia. Heart attacks are caused by a chemical imbalance: too many of the wrong kinds of lipids and lipid-related plaques in the coronary arteries.

I can get even more nitpicky if you want. The Donner Party died of chemical imbalance – too few fatty acids, proteins, and carbohydrates. The passengers of the Titanic died of a chemical imbalance – H2O in the lungs instead of O2. And it was a chemical imbalance that got Hiroshima in the end: excess uranium-235. Anything that’s not caused by ghosts is going to be “a chemical imbalance” in some sense of the word.

This is why I’m being so insistent that psychiatrists referred to “a chemical imbalance” rather than “a serotonin deficiency”. They were hedging the heck out of their bets. It might be BDNF, or cytokines, or whatever. But if something happens in the body and doesn’t show up as a gross anatomical defect on MRI, it’s a pretty good bet it’s chemical in some sense of the word.

So is this a giant cop-out? Psychiatrists said “it’s a chemical imbalance” to make it sound like they knew what they were talking about, when in fact all they meant was “it’s a thing that exists”?

Sort of.

Anything that isn’t caused by ghosts is going to be “a chemical imbalance” in some sense of the word. But in the latter half of the twentieth century, “depression is not caused by ghosts” was a revolutionary statement, and one that desperately needed to be said.

I still see this. People come in with depression, and they think it means they’re lazy, or they don’t have enough willpower, or they’re bad people. Or else they don’t think it, but their families do: why can’t she just pull herself up with her own bootstraps, make a bit of an effort? Or: we were good parents, we did everything right, why is he still doing this? Doesn’t he love us?

And I could say: “Well, it’s complicated, but basically in people who are genetically predisposed, some sort of precipitating factor, which can be anything from a disruption in circadian rhythm to a stressful event that increases levels of cortisol to anything that activates the immune system into a pro-inflammatory mode, is going to trigger a bunch of different changes along metabolic pathways that shifts all of them into a different attractor state. This can involve the release of cytokines which cause neuroinflammation which shifts the balance between kynurinins and serotonin in the tryptophan pathway, or a decrease in secretion of brain-derived neutrotrophic factor which inhibits hippocampal neurogenesis, and for some reason all of this also seems to elevate serotonin in the raphe nuclei but decrease it in the hippocampus, and probably other monoamines like dopamine and norepinephrine are involved as well, and of course we can’t forget the hypothalamopituitaryadrenocortical axis, although for all I know this is all total bunk and the real culprit is some other system that has downstream effects on all of these or just…”

Or I could say: “Fuck you, it’s a chemical imbalance.”

Last time I talked about the definition of disease I said that people want diseases to “be caused by the sorts of thing you study in biology: proteins, bacteria, ions, viruses, genes.”

I don’t think I could actually get away with telling a patient’s family “it’s caused by, you know, biology stuff” without them asking if I really went to medical school. I don’t think I’d use the term “chemical imbalance” precisely; too likely to trigger a knee-jerk reaction from people reading exactly these articles I’m responding to. But I think I would say something alone those lines. “We don’t know exactly, but it probably involves problems with brain structure and brain chemicals,” maybe. That covers about the same ground as “biology stuff” while also sounding like I’m at least trying to answer their question.

So if what I’m actually saying with that is “depression is caused by complicated biology stuff you don’t understand, and not by things like your son not really loving you, or being lazy,” am I sure that’s right?

I won’t say all depression is 100% caused by internal failures of biology in the same way that for example cystic fibrosis is caused 100% by internal failures of biology. I am happy to admit that some depressions can be caused by being in a crappy social situation, being abused as a child, being stuck in an unhappy marriage, being worried about problems at work, stuff like that.

But it’s far from obvious that being stuck in an unhappy marriage should drain your energy, drain your concentration, make you stop enjoying your hobbies, and finally drive you to suicide. We can imagine another person, or another way of designing a person, where someone says “I hate my husband, so I try to stay away from him as much as I can by working extra hard and spending my free time playing frisbee with my dog in the park.” But instead, someone hates their husband, and it drives all the joy out of their life to the point where they can’t go to work, they can’t play with their dog, they just sit around wishing they were dead.

And is that the fault of “biology stuff”? That’s a harder question than it sounds. What would it mean to say ‘no’? If we are strict materialists who don’t believe in some kind of division of labor between the brain and the soul, then yes, if it’s a feeling you’re having, it’s based in biology.

I’ve previously said we use talk of disease and biology to distinguish between things we can expect to respond to rational choice and social incentives and things that don’t. If I’m lying in bed because I’m sleepy, then yelling at me to get up will solve the problem, so we call sleepiness a natural state. If I’m lying in bed because I’m paralyzed, then yelling at me to get up won’t change anything, so we call paralysis a disease state. Talk of biology tells people to shut off their normal intuitive ways of modeling the world. Intuitively, if my son is refusing to go to work, it means I didn’t raise him very well and he doesn’t love me enough to help support the family. If I say “depression is a chemical imbalance”, well, that means that the problem is some sort of complicated science thing and I should stop using my “mirror neurons” and my social skills module to figure out where I went wrong or where he went wrong.

In other words, everything we do is caused by brain chemicals, but usually we think about them on the human terms, like “He went to the diner because he was hungry” and not “He went to the diner because the level of dopamine in the appetite center of his hypothalamus reached a critical level which caused it to fire messages at the complex planning center which told his motor cortex to move his legs to…” – even though both are correct. Very occasionally, some things happen that we can’t think about on the human terms, like a seizure – we can’t explain in terms of desires or emotions or goals an epileptic person is flailing their limbs, so we have to go down to the lower-level brain chemical explanation.

What “chemical imbalance” does for depression is try to force it down to this lower level, tell people to stop trying to use rational and emotional explanations for why their friend or family member is acting this way. It’s not a claim that nothing caused the chemical imbalance – maybe a recent breakup did – but if you try to use your normal social intuitions to determine why your friend or family member is behaving the way they are after the breakup, you’re going to get screwy results.

(in much the same way, if I just saw you take a giant handful of amphetamines, I pretty much know why you’re having a seizure, but I still can’t rationally / intuitively model the experience of why you’re “choosing” to move your limbs the way that you are.)

(though it’s important for me to temper this by mentioning that many people diagnosed with depression don’t have it)

There’s still one more question, which is: are you sure that depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?

And part of what I’m going on is the stated experience of depressed people themselves. As for the rest, I can only plead consistency. I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala. I think large-scale variations in crime rate are mostly attributable to environmental levels of lead and probably other chemicals. It would be really weird if depression were the one area where we could always count on the inside view not to lead us astray.

So this is my answer to the accusation that psychiatry erred in promoting the idea of a “chemical imbalance”. The idea that depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry. The idea that depression was a complicated pattern of derangement in several different brain chemicals that may well be interacting with or downstream from other causes has always been taken seriously, and continues to be pretty plausible. Whatever depression is, it’s very likely it will involve chemicals in some way, and it’s useful to emphasize that fact in order to convince people to take depression seriously as something that is beyond the intuitively-modeled “free will” of the people suffering it. “Chemical imbalance” is probably no longer the best phrase for that because of the baggage it’s taken on, but the best phrase will probably be one that captures a lot of the same idea.

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248 Responses to Chemical Imbalance

  1. switchnode says:

    In case anyone else was too busy wondering where one got depressed macaques to pay attention: you don’t, you make them (by making their mothers forage erratically). Delightful.

    • Deiseach says:

      I did wonder how you would know if a macaque was depressed. And this is why James Tiptree, Jr. titled one of her stories “The Psychologist Who Wouldn’t Do Awful Things To Rats”.

    • randy m says:

      Once they figure out how depression works you won’t feel so bad about the abused monkeys.

      • switchnode says:

        That was sincere, not sarcastic. Depressed monkeys were the funniest thing I’d imagined all day.

  2. Shmi Nux says:

    So the way we (well, you, psychiatrists and your hated cousins psychologists) decide on the better level of modeling a malady is by what works best to fix it: if drugs work, it’s chemical imbalance, if incentives work, it’s behavior/free will, or something. So, if exorcism works, then it might as well be ghosts?

    • Shieldfoss says:

      It works like that in Electronics Engineering, too – sometimes, electricity is a real thing, and current is a real thing. Other times, you consider the individual electrons and the way the electric field forces are pushing them. It works like that in Automation Engineering, too – sometimes, an equipment module is a real thing, and water flow is a real thing. Other times, you consider the individual valves and motors that are moving the water.

      I don’t want to Typical Mind it here, but from my perspective it seems that unless you’re using the real real – the quantum mechanical underpinnings – then every field is always about finding the abstraction layer that works best for your current problem. Are things different in your field?

      In fact, let’s throw that one open to every commenter – are there ANY of you who work in a field where there is one, single, model which is always used?

      • Corey says:

        “…unless you’re using the real real – the quantum mechanical underpinnings – then every field is always about finding the abstraction layer that works best for your current problem. Are things different in your field?”

        I believe Shmi Nux’s field is, in fact, quantum physics.

    • Isnt that the way everyone handles causality? Everyone has the It’s Complicated theory of causality in the background,, everyone wants to know The Single Cause …. ie, where do I apply pressure to fix it…in the foreground, in particular cases they have to deal with.

    • Scott Alexander says:

      No, that’s the “antibiotics cure pneumonia, so pneumonia is an antibiotic deficiency” reasoning I was arguing against.

      The reason I think depression is probably chemical to a degree that makes it not easily explicable socially is because of the reports of depressed people, plus its being on a continuous spectrum from mild depression that some might be tempted to explain as laziness, all the way to very severe depression where people die of starvation because they won’t get out of bed to eat. Nobody’s that lazy. Which implies that there is at least some possibility of weird outside-normal-human-experience depression, and once you’ve got that category you can use it to understand the less severe versions.

      (also, there might be a definitional thing involved; once we know some depressions are outside-normal-experience and probably biochemical, and we’ve defined depression as involving that, there’s an argument that if some other people are just people being lazy, then that doesn’t mean depression is sometimes just laziness, it means they’re not depressed and if someone said they were it was a misdiagnosis)

      • Deiseach says:

        “Laziness” is a fuzzy enough concept; there’s “I could get up and [do thing] if I wanted, but I’m too comfortable where I am to do that” versus “I could get up and [do thing] if I wanted, but I can’t even want”.

        Plus that brings us back to willpower and “pull yourself up by your bootstraps”, which is no good telling people when they’re depressed. “Make an effort, don’t just sit there!” is not any help when you can’t see any reason to move, or you do see a reason, you simply can’t get the “see reason” + “move” parts of the brain to work together.

      • nydwracu says:

        There are weird outside-normal-human-experience things that are neither biological in the common sense nor failures of virtue — things that are caused by environments.

        Take learned helplessness: you can black-hat hack the brain’s learning centers to get dogs (and presumably people) to submit to pain even when they can escape. Apparently there’s a learned helplessness theory of depression, even.

        What happens if you put someone in an environment where they’re surrounded by people who are going to default to not liking them? Do people who grow up in small and generally disliked groups have higher rates of anxiety disorders? How about people from high-crime areas? Is there data by neighborhood of origin somewhere?

        • Creutzer says:

          an environment where they’re surrounded by people who are going to default to not liking them?

          Wait, this does not describe essentially the entire world? I… think I missed something.

        • Paul Torek says:

          Exactly. Note also, once you suffer such experience, it changes your brain. Most obviously it lays down memories and conditions emotional responses. But also, for example, abused children have smaller left hippocampuses. And I’ll bet you at ridiculously long odds that traumatic experience influences one’s level of one or more neurotransmitters.

          • nydwracu says:

            Right — the key point here is that it should be a lot more salient than it is that experiences can have major effects on brain states. (The example that prompted this: I noticed that I keep seeing people get wrapped up in partisan politics and start writing like speed freaks even though they’re not ingesting any chemicals less socially accepted than marijuana, if even that.)

          • Who wouldn't want to be Anonymous says:

            On the “once you suffer such experience, it changes your brain” front, there is evidence of heritable epigenetic changes in PTSD sufferers. This looks like a relevant citation.

            On the depression front, it looks like we are seeing the same thing.

            I haven’t read the research but it seems plausible. If someone wants to dive into it…

      • loki says:

        Yeah – as a datapoint (I am bipolar, so my depression may not be the same as people with depression’s depression, but it is similar to a lot of people’s descriptions) my bipolar moods don’t feel like normal moods. Normal moods seem to have the following traits:

        * They almost always have an identifiable cause that is more or less in proportion, from the subjective view of the person whose mood it is, with the strength of the mood. Losing a parent = more severe sad than, say, losing a pen.
        * They can usually be worked past with willpower. The difficulty of doing this is roughly in proportion to the strength of the mood, though it also seems clear that ‘work past mood’ is a skill people possess in varying amounts. You cannot necessarily change your mood this way but you can stop it from overly affecting your outward behaviour. Sometimes you can change your mood – you can cheer yourself up somehow, or a thing might happen that makes you sad even though you were previously happy.
        * They last a reasonable amount of time, for a given definition of reasonable. Again, this depends on the cause. I might be sad or frustrated for five minutes if I lose my 50c bic, but the loss of a pen of great monetary or sentimental value will affect me for longer as well as more intensely.

        Bipolar moods, for me, have the following traits:

        * They have no identifiable cause. Sometimes this is literally ‘I feel x for no reason’, sometimes my mind will rationalize that y event must be the cause because it’s roughly the right sort of trigger, but on reflection I actually felt that way before y happened and that just caused me to notice it, or y is entirely too small to cause this length/intensity of mood.
        * They are much harder to work past with willpower. It is not impossible to willpower it to the point where it does not overly affect outward behaviour, but this is difficult and consumes and energy source that feels limited. It is, as far as I can tell, not possible to ‘cheer up’ or ‘bring down’ these moods in the same way. New, real, moods just layer themselves over the larger canvas of the bipolar mood.
        * They affect energy levels to a much greater extent than normal moods. Normally, people will have a bit more energy if they’re in a good mood or angry, and less if they are down. Bipolar moods greatly exaggerate this to the point where it has a powerful effect on how much sleep you get and how much productive work you can do.
        * They last a completely random amount of time, but often much longer than normal moods that are not prompted by extreme and rare events. So Bipolar Moods might make me anxious for a week or so, whereas events that would cause someone to be anxious for that long with normal moods happen but are much rarer than moods that make you jumpy for a few minutes or hours.

        This was a ramble, but the point is that they *feel* chemical. They feel like something that might plausibly be caused by, say, a make-x-emotion drug slipped into my drink, rather than an actual event in my life.

        In fact the sensation when a mood comes on with no identifiable cause is very similar to when a drug provokes a certain mood (like weed making one feel calm, or paranoid) when nothing is provoking that mood other than having taken that drug.

  3. Sniffnoy says:

    Regarding Hiroshima, if you care about particular isotopes, wouldn’t that make it a nuclear imbalance? 🙂

  4. OK so everything is caused by chemicals, and calling something a “chemical imbalance” is really a way to tell people to think about the problem at a lower layer than emotions intension. We still have a problem. You could say that about anything in human affairs. “Why did Johnny rob that liquor store? Chemicals.” Psychiatry doesn’t just get to baldly assert that a low-layer description is the best way to think about depression. It has to actually make the case. And the way it made the case was with “chemical imbalance” talk, which isn’t an argument, it’s an assertion. The case has to involve actual features of depression, not just generic features of biology that could describe why anyone did anything.

    • Tracy W says:

      Isn’t that what Scott Alexander just did?

      • Mostly, but where I think I disagree is the extent to which the case has been made. It seems like the strongest argument for thinking about depression in a low-layer way is the existence of effective low-layer interventions that fix it. Its not clear to me that the low-layer interventions are good enough to make high-layer ones obsolete.

        • Tracy W says:

          There’s a difference between “I didn’t find your arguments totally convincing” and “this isn’t an argument, it’s an assertion.”

        • Scott Alexander says:

          I don’t think high-layer interventions are obsolete. Compare to a drunk person. They have various problems like being angry and violent. To some degree the same things that help avoid anger and violence with anyone else will work on them – being nice to them, having calm body language – but it’s much harder for them, you’ll probably go wrong if you try to model their anger using your own emotions as a guide, and the definitive treatment is to have them not be drunk.

    • Celestis says:

      I am pretty sure that Scott Alexander answered that exact question, immediately after posing it like this:

      “There’s still one more question, which is: are you sure that depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?”

      It is also not clear to me that Johnny didn’t rob a liquor store because of some sort of mental illness.

      Edited for clarity.

    • PGD says:

      Yeah, I agree with this criticism, and also think that Scott did not respond to it effectively. (Although to his credit he ends up acknowledging it in kind of a backhanded way). The rhetoric around depression being ‘chemical’ has lots of effects — channeling patients to chemical interventions controlled by psychiatrists, channeling money and prestige to psychiatrists, lowering patients sense of self-blame and personal responsibility, transferring agency to outside medical professionals like psychiatrists. But Scott ends up making the case that the rhetoric itself is not very meaningful insofar as everything is kinda sorta chemical. Using that rhetoric would signal something meaningful if it was standing in for a complex but reliable top-to-bottom psychiatric understanding of depression at the level that medical doctors understand e.g. diabetes, which Scott uses as an (IMO somewhat misleading) metaphor. But it is far from clear that psychiatry does understand the mechanical processes of the brain well enough to isolate and treat ‘depression’ in a fully reliable way. In the absence of such evidence the charge that the ‘chemical imbalance’ language is basically designed to propagandize for psychiatry and delegitimize any alternatives still has plausibility.

      • FeepingCreature says:

        So what alternate model or approach are you proposing?

        I mean – we live in a capitalistic system. If medication works, then funnelling money into medication is in fact the system working as designed. Regarding self-blame … does self-blaming work against depression? If not, again, lowering patients’ sense of self-blame is a success.

      • Deiseach says:

        lowering patients sense of self-blame and personal responsibility

        There are things depressed people can do to help themselves when they’re depressed. Unfortunately, when you’re depressed, you have no initiative, no energy, no sense of hope, no reason to do anything. So heaping on the blame is not going to help; depressed people already self-blame.

      • Tracy W says:

        Wouldn’t rhetoric about depression being “ghosts” equally have lots of effects — channelling patients to ritual interventions controlled by priests money and prestige to priests, lowering patients sense of self-blame and personal responsibility, transferring agency to outside ritual professionals like priests?

        But it is far from clear that psychiatry does understand the mechanical processes of the brain well enough to isolate and treat ‘depression’ in a fully reliable way.

        It’s far from clear that civil engineering does understand the mechanical processes of materials well enough to build safe buildings in a fully reliable way.

        • SFG says:

          Most buildings don’t fall most of the time. We have building codes and so on that people will cut corners on to save money, and eventually all buildings fall, but most of the time, civil engineering works.

          • Tracy W says:

            Yes. Most of the time. Quite different to being “fully reliable”. (And I’m not talking about cutting corners to save money but totally unexpected failures because the theory wasn’t good enough.)

        • John says:

          I think I get what you’re pointing at, but really, buildings falling down? A number so small as to be lost in the statistical noise, I think.

          • Tracy W says:

            That’s because engineers massively over-engineer them, costing more in materials than would be the case if they did understand materials science. If overbuilding was as dangerous as overmedicating there’d be a lot more fallen buildings.

      • Steven says:

        Er, yes, it is absolutely true that psychiatry doesn’t understand depression well enough to treat it in a fully reliable way. And everyone in the field knows it.

        Which doesn’t change that the “alternatives” are utterly reliable faliures in a way perfectly predicted by saying that depression is a chemical imbalance.

        It’s like saying that oncology doesn’t understand cancer well enough to treat it in a fully reliable way. Yep, that’s right. And if you accordingly scorn chemotherapy and surgery in favor of aromatherapy and cupping, you wind up dead. Imperfect understanding beats pants-on-head lunacy.

      • Paul Torek says:

        This. Scott’s (B) is a straw straw-man. Scott’s (A) is a motte.

        (A): Depression is complicated, but it seems to involve disruptions to the levels of brain chemicals in some important way

        (B): We understand depression perfectly now, it’s just a deficiency of serotonin.

        The bailey is

        (B minus): The primary fundamental underlying cause of mental illness is neurotransmitter imbalance(s).

        And that is not something that Mad In America made up. (Good to know that Scott is reading that, though – might improve the balance of information.) It is the core of an extremely successful ad/propaganda campaign by Big Pharma, in which psychiatrists often played a significant role.

        According to John Read (pdf), Steven Sharfstein, the APA President (P for Psychiatry), commented in 2005:

        We must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model.

        and

        Financial incentives and managed care
        have contributed to the notion of a ‘quick fix’ by taking a pill and reducing the emphasis on psychotherapy and
        psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists
        than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications

        If you want evidence that Big Pharma (or somebody, at least) really did push a “chemical imbalance” just-so story, just interview people at random. That’s what former psychotherapist Daniel Mackler did in his movie Take These Broken Wings – described here – after he became disgusted with the bio-bio-bio model’s dominance of his field and of the medical insurance industry. The results are embarrassing to watch, even if you haven’t just written a post minimizing the importance of the “chemical imbalance” mantra.

        I think Scott needs to rethink his own biases:

        I have no personal skin in this game.
        [… 2.5 intervening sentences]
        I would like to defend my profession.

        Well, that didn’t take long.

  5. Douglas Knight says:

    Thanks for using the phrase “bait-and-switch.”

  6. Ishaan says:

    “brain malfunction”? Maybe malfunction is too negative. Maybe “disregulation?”

    “I think the _ symptoms are biological in nature” is a straightforward way to explain it, though. Perhaps you’re underestimating less glib versions of “biology stuff”?

  7. Said Achmiz says:

    So, depression prevents us from being able to take the intentional stance toward a person, and forces us to take the physical stance (skipping the design stance, interestingly)?

    • Decius says:

      We could take the design stance, but then we would have to say that things are malfunctioning, and drop to physical stance to explain what is malfunctioning and why and what the malfunction is.

  8. Decius says:

    >There’s still one more question, which is: are you sure that depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?

    Why not ask depressed people who can model both healthy people and their own actions what the differences are between what a specific healthy person would do in their situation, versus what they would do?

    I suspect that the answer will be “They would do X, but I will do Y, because I just don’t have the energy to put on clothes when I get up in the afternoon.”

    You could call that laziness… if you were a heartless bastard who didn’t care about making people better. Because the typical cure for “laziness” is making life suck more for the “lazy” person, and you literally can’t make life worse for someone whose brain doesn’t have working “suck less” chemicals.

    • eqdw says:

      Why not ask depressed people who can model both healthy people and their own actions what the differences are between what a specific healthy person would do in their situation, versus what they would do?

      I believe I fit this bill. Do you have any specific questions or prompts? I’ll try my best to answer them, if you do.

      • Decius says:

        Sure. Think of a specific person who fills a responsible role. Predict what they would do if you told them that something within their area of responsibility needed done, then test that prediction. That makes sure that you can do basic modeling of a (presumed) nondepressed person.

        Then think about a situation that you expect to encounter in the near term, and predict what you will do about it. Test that prediction, to make sure you can model yourself.

        Then swap the two people; what would you do where something needed done, and what would they do in your situation. If possible, try to test those predictions.

        Then go on and talk about your internal narrative vs. the other person’s, and establish why the difference exists (if it doesn’t, why do you think you are depressed?)

        • eqdw says:

          Shit. This is harder than expected.

          On a general level, my internal model of what’s going wrong in my brain, vs going right in others’, is that I get tripped up in pessimism, anxiety, and lack of energy.

          There is a thing that needs doing. The nondepressed person does it. Because you do things that need doing. I, maybe do, maybe don’t. If I don’t, it’s some combination of pessimism (“why bother, it won’t work anyway”), anxiety (“but what if happens”), and depressive lack of energy (“it seems like too much work, and if I don’t do it, it won’t be *that* bad”)

          I couldn’t actually positively model the nondepressed person’s internal narrative beyond “not-what I just said”. However, I’ve recently made great strides in fighting my own demons (mostly but not entirely through medication), and when I’ve overcome depression, it really is just the lack of those three internal narratives above. Or sometimes not a lack, but they just seem somehow weaker and less daunting

    • Careless says:

      Oh, come on, there are many levels of depression, and for most depressed people, things could get worse.

      Not that I’m, you know, advocating doing such

      • Decius says:

        I think you are empirically wrong about that.

        “Worse” is kinda subjective, but there are ways to measure happiness. If you try make a person who is at the point of not being able to get out of bed feel worse, I think that you will fail.

        Certainly you can do things that make you think they are worse off, like throwing a bucket of ice water on them, but does that actually reduce the chemical structure that is their happiness, or does that just strike at the ghost of happiness?

        • Careless says:

          Very few depressed people are that depressed. Not sure why that would surprise you.

  9. eqdw says:

    My two cents:

    I have been “depressed” since. For the longest time, I did not believe my own diagnosis. My parents were emotionally abusive, I went through a lot of stress that forced me to grow up quickly. I was a social failure, and a romantic failure, awkward, nerdy, etc. I was bullied. I always assumed that I wasn’t depressed, so much as I was just unlucky and had a shitty life.

    In 2006 I started a long hate-affair (it wasn’t love) with SSRIs. I started on a low dose (25mg?) of Sertraline. I fundamentally didn’t believe I needed this, but it was part of the plausibility dance that let me shirk blame when my parents were upset at me (“*I* didn’t piss you off. It was the depression talking”, shit like that).

    The fact that this drug seemed to have no effect whatsoever (aside from tinnitus and dizzy spells when for the first two weeks when I started it) lent more credence to “not depressed, shitty life syndrome”

    Between then and now, I’ve been on and off SSRIs. I’ve tried Sertraline (no effect), Citalopram (extremely negative side effects; lost 6lbs in a week due to nausea and lost the ability to orgasm), Fluoxetine (mild diminished sex drive, unknown/don’t remember if it helped), Paroxetine (severely diminished sex drive, extreme mood swings and suicidal ideation when I discontinued too fast because fucking primary doctor can’t read goddamn Wikipedia and gave me dangerously bad instructions), and Bupropion (unknown mood effects but the side effects are awesome). To the best of my knowledge, *none* of these (except maybe Bupropion) have made any lick of difference to my mood.

    However, I spent the last two years in a serious relationship with a woman who suffered both chronic physical and mental health issues, and has tried much more than I have. Among other things, she definitely opened my eyes to the idea that a lot of complex depression symptoms can be traced to super simple biology/health considerations.

    As a quick example: I suffer the constant depression symptom of lack of energy. But I fixed it: turns out getting 2 hrs more sleep every night, and ~400mg more caffeine every morning, is all I needed. Or in her case, ~70% of her changes in depression and anxiety could be explained by her forgetting to take a pill or hormone one day.

    Depression is complicated. To this day I still believe that the main cause of my depression is shitty parents syndrome. But I’m finding more and more evidence in my personal life that, regardless of whether it’s *caused* by, or simply mediated by, chemicals, the right chemical interventions are a hell of a lot more effective than anything else.

    Ultimately, I want to yell at every single non-MD who writes about depression, antidepressants, etc: YOU DON’T KNOW WHAT IT’S LIKE. It sucks. A lot. I’ve come extremely close to killing myself almost a dozen times in my life. It’s horrifying. I occasionally have anxiety attacks over *the fear of the fact that in the future I might become suicidal again*. What the fuck is that even.

    Why is this my demon to fight? Is it chemical? Behavioural? Environmental? Historical? Emotional? IT. DOESN’T. MATTER. What matters is that some strategies work for some people, and people who suffer this are critically in need of working strategies. “Chemical imbalance” vs “genetics” vs “environment” doesn’t matter. What matters is fixing the problem. If drugs work for some people, then that’s what they need. If they don’t, then they need something else.

    • The urgency that you’re talking about reminds me of The Parable of the Poisoned Arrow.

      FWIW, I (think I) understand what you mean; there are situations I’ve been in that made me feel the same way (though not with the same intensity, I suspect); and things which I intellectually think are very urgent, though because they don’t affect me (immediately) I don’t feel the urgency.

    • PGD says:

      The problem is that when the ‘its a chemical imbalance’ story is used to support the unique expertise of psychiatry and its prescription-protected complex drugs, that works to reduce the legitimacy of simple physical explanations as well. E.g. ‘get more sleep and more exercise’ is not the kind of intervention supported by chemical-imbalance language in the real world. Further, making things like the ‘more sleep and more exercise’ prescription work usually requires some kind of supportive social intervention, as you appeared to have with your girlfriend. The efforts we have put into chemical cures has subtracted to, not added from, our collective efforts to create supportive social interventions.

      • FeepingCreature says:

        I just want to note here that SSRIs do in fact work for many people. Do you have a study on the relative effectiveness of “more sleep and a cup of coffee” vs prescription medication?

      • Deiseach says:

        It’s chicken-and-egg: get out in the fresh air and get exercise is certainly a recommendation to cope with depression that support groups, counsellors, doctors, etc. do recommend (along with counselling, medication and so forth).

        The trouble is, to get the good effects of exercise, you have to go outside and exercise. And when you can’t force yourself to take off your nightclothes and get dressed because that is too much effort, how are you going to make the effort to open the front door and walk out and go for that brisk walk, run, swim or other exercise?

        I’m literally dragging myself to work these mornings; I walk to work, but I stop about every ten minutes and just freeze in place because I have to build up the psychic energy to make myself move. I’d stay standing in one spot for hours if I could (it’s only the mental nagging I do of “You have to go to work, you have to go to work” that gets me going when the reservoir of psychic energy slowly refills). That’s depression in action.

        • eqdw says:

          > The trouble is, to get the good effects of exercise, you have to go outside and exercise. And when you can’t force yourself to take off your nightclothes and get dressed because that is too much effort, how are you going to make the effort to open the front door and walk out and go for that brisk walk, run, swim or other exercise?

          This is very true. This is, I think, one of the places where medication helps. It helps to get one over that activation-energy hump and makes it easier to make the kind of positive lifestyle changes that are correlated with anti-depression

          • Paul Torek says:

            That’s a good strategy. Kick-start yourself with drugs. Then – I would suggest – try to get off them before the side-effects get too nasty or permanent.

      • Anonymous says:

        “E.g. ‘get more sleep and more exercise’ is not the kind of intervention supported by chemical-imbalance language in the real world.”

        On the contrary, “Get more sleep” is completely in line with the chemical imbalance story. The reason it isn’t being embraced in the real world is because sleep need is all-but-stigmatized. (Just try telling people you need over 9 hours of sleep in order to function.)

      • Izaak Weiss says:

        I have to say, as someone with ADHD (not depression but maybe this is similar), I have been prescribed drugs but before, during, and after that my doctor gave me many variations on the “get more sleep, eat better, and exercise” speech. In my experience, doctors use both approaches, not just one.

        • Anonymous says:

          Yes, doctors will say “get more sleep.” But when have you heard someone say, “Oh, you’re getting 7-8 hours of sleep and still feel tired? You should try 9 or 10”?

          • Izaak Weiss says:

            Literally from my general doctor and the person I meet with to talk specifically about ADHD (I can’t remember exactly what degree she has but its something to do with helping people with mental disorders).

            I’ll tell them that I usually sleep between 12 and 1, and then have to wake up for classes between 7 and 8, and they tell me that I should try to sleep between 10 and 11 so that I can get 8-10 hours of sleep.

          • Anonymous says:

            OK, I have heard of it now! 🙂

        • eqdw says:

          Incidentally: sometimes I wonder if I’m not actually depressed, just ADD. My main evidence is that SSRIs never did shit for me, but Wellbutrin (an amphetamine-based antidepressant) has worked wonders. As has 400mg caffeine.

      • James Picone says:

        I’ve actually had a GP recommend more exercise in the context of minor depression, and a local depression-and-mental-health charity hands out a booklet listing an extremely wide variety of interventions for depression with some details on clinical effects and safety. Exercise, diet, and sleep are all mentioned in there.

        • eqdw says:

          Virtually every resource I can find (including most medical professionals I speak to) will cite sleep, nutrition, and exercise as the first line intervention.

          I have no idea who all these people are who think that everyone’s just pushing pills.

          Course, I also stand by what I said at the top level: If drugs work for people, fuck you for shaming them. Pharmacological Calvinism doesn’t help anyone

      • eqdw says:

        > The problem is that when the ‘its a chemical imbalance’ story is used to support the unique expertise of psychiatry and its prescription-protected complex drugs, that works to reduce the legitimacy of simple physical explanations as well.

        I have *never, ever* had a medical professional imply that magic pills will make things better. I have only ever had them say “hopefully these will get you over the hump, but they won’t do it all for you. You should do “.

        I’m willing to accept that my experience was atypical. Most of the psychiatric professionals I saw were in Canada. After I moved to the US, I was very well read on the subject of depression, anti-depressants, what they do, what they don’t do, effective interventions, etc. Once I moved here, my visits to professionals basically consisted of “I would like to try this drug to see if it works, please”

      • David Allen says:

        Exercise and sleep are two things well known to change the chemical balance of both body and brain. Exercise requires will to do, though, and for depressed people it can be a non-starter. Sleep can often be encouraged through drugs. I know more than one person who was suffering from major depression before they got drugs that let them sleep.

  10. Celestis says:

    In the Atlantic article talking about how ” many people diagnosed with depression don’t have it”, they mention that people previously diagnosed with Major Depressive Disorder no longer meet criteria because they haven’t had a major depressive episode in the past 12-months. But of the people with “unconfirmed” depression, most had been put on antidepressants.

    Am I missing something? When were these follow-ups conducted? If it was more than 12 months after the diagnosis, it might easily point to the effectiveness of antidepressants (i.e. they were depressed before, but not now because they are on antidepressants), though that seems silly and I assume the study was looking at the same time period. If they were being questioned about the same time period, how were the different interviews yielding different results? Does this just mean that the interview methodology is flawed? Unfortunately the paper itself is behind a pay-wall I can’t pierce.

  11. Null Hypothesis says:

    “so take all the biology and studies in here with a grain of salt until you double-check.”

    Why? Is misunderstanding your disclaimers a symptom of a brain-salt deficiency? Who are you to be giving out prescriptions on a blog anyway?

    • PDV says:

      Take this blog post with two grains of salt and call me in the morning.

      • Deiseach says:

        Make sure it’s sea salt, so you get your iodine requirement 🙂

        • houseboatonstyx says:

          Okay, we’ve had literal caffeine.
          Plus metaphorical salt.
          Is your salt metaphorical, being governed by its most recent context?

        • Null Hypothesis says:

          Yes, Blog Doctor? I took the salt, and one of my feet fell off while I was sleeping. Now I don’t feel like getting out of bed. I think I might be depressed.

          Please advise.

          • Deiseach says:

            Matthew 5:13

            You are the salt of the earth. But if the salt lose its savour, wherewith shall it be salted? It is good for nothing any more but to be cast out, and to be trodden on by men.

            Are you certain the salt was not past its best-by date? That may result in foot-falling-offness and lack of savour 🙂

  12. Daniel Speyer says:

    I know I’m nitpicking here and this isn’t the point, but…

    It seems entirely possible that depressed brains have total molecule counts within the same range as healthy, and the problem is arrangement of those molecules at a larger scale (e.g. which neuron has a synapse on which). It’s hard to call that a “chemical imbalance”.

    It also seems possible that some molecule (possibly a serotonin receptor) is missing entirely and replaced by a mutant version. In healthy people, there’s no “balance” between wild type and mutant receptors — there’s just wild type. So it’s hard to call that an “imbalance” either.

    I would expect these cases to be harder to treat with drugs than the classic “your X level should be between y and z ppm, but it’s w” type of imbalance.

    • Shieldfoss says:

      If I have a scale with a pound-weight on either arm, and a different scale with two pounds on the one arm and no pounds on the other, I will feel fully justified calling the second one imbalanced though it has the same weight count as the first.

      Once we have precise and accurate nanotechnology that can reach into the brain and redistribute the serotonin until it is correctly placed, the current solution of “Throw in more weights, hope they lands on the correct arm” might well be the best solution we have for certain classes of problem.

  13. Harald K says:

    “In the case of alcohol we pretty much know what’s going on” you write, and then you write a story that is contradicted by anthropological observations and really old controlled studies. Alcohol does not reduce inhibitions in all cultures, and where it does reduce inhibitions, it does so just as well with a placebo, and it does so before alcohol even reaches the bloodstream.

    You’ve told a plausible story about why alcohol reduces inhibitions – it should really increase inhibitions, but it inhibits the part that reduces inhibitions first! – with the help of neuroscientists who have asked for years “how is it that alcohol reduces inhibitions?”. The only problem is that it doesn’t.

    But unlike the “chemical imbalance fraud”, the reduced inhibitions fraud is still going strong some sixty years after it was first challenged, supported by the fact that just about everyone in our culture uses this supposed reduced inhibition effect as part of social rituals. It isn’t going anywhere.

    • Alexander Stanislaw says:

      That is orthogonal to the point Scott was making (which is that biological systems can act in non-linear ways). Possibly a bad example, but the general point is still true.

      I found this book making some of the arguments you have. Before I say why I think they do not show what they purport to, is the evidence cited what you had in mind?

      • Harald K says:

        I haven’t read that book, but probably. Here is a chapter from a book which links many of the important studies (and makes an argument from them).

  14. lmm says:

    Can you give some examples of subjects that it is better to treat as a personal failing / free will thing rather than a medical thing? If we’re judging by self-report and the effectiveness of treatment strategies, then another threads example of “robbing liquor stores” seems like something that’s better treated as a chemical imbalance than a moral failing. Likewise e.g. weight issues.

    • Tracy W says:

      People responsive to behavioral incentives rob liquor stores but not the cafeteria at the police station. People responsive to behavioral incentives lurk around atms to mug people with money, they don’t lurk around motorway on-ramps. Someone who beats their spouse but doesn’t beat their boss or friends, or try to beat the bailiffs at court is responsive to behavioral incentives.

      • lmm says:

        Depressives take certain actions and don’t take other somewhat similar actions, don’t they? What’s the distinction you’re drawing here?

        • Tracy W says:

          Not getting out of bed to eat even though you’re starving is on the level of trying to beat up the bailiffs at court, or mug people on a motorway on ramp, or robbing the police station’s cafeteria.

      • Mary says:

        And doesn’t beat the spouse except in private. Theodore Dalrymple has known battered women who insist it’s some kind of fit, he can’t control it, but who yet realize that his “fits” only happen in private.

  15. “All I’m saying is that depression is complicated.”

    Aren’t you saying that causality is complicated?

    • Izaak Weiss says:

      Some causality is less complicated, and some causality is more complicated. Depression, as a subset of causality, is on the side of more complicated things. An example of something that is less complicated, being shot by a gun in the left arm has a much simpler and much stronger chain of causality linking that action to pain and unhappiness than depression has to pain and unhappiness.

  16. Lancelot Gobbo says:

    ‘Chemical imbalance’ is a term I associate with American daytime TV talk shows. I have never heard a psychiatrist use it. Furthermore, to quote speeches made by past presidents of the APA hardly proves a thing. We all know the kind of physicians who are drawn to committees and being active in our various medical societies – they aren’t cutting edge clinicians but rather those who are looking hard for an alternative to getting their hands dirty seeing patients. I wouldn’t be in the least surprised if one of them had heard about ‘chemical imbalance’ from Dr Phil and thought it was a real thing. Easier than reading the journals. I know I’m not supposed to tell ‘the bitter, old and wrinkled truth’ to the very young, but Scott, you’ll learn it for yourself sooner or later.

    • PGD says:

      Why did the ‘chemical imbalance’ language appear on Dr. Phil, on TV ads, and spread like wildfire throughout the broader population right around the time all these new drugs appeared that only psychiatrists could prescribe? Could the psychiatry profession possibly have had anything to do with it?

      • Ptoliporthos says:

        Arvid Carlsson got the Nobel Prize in 2000 for a vast body of work that includes the discovery/invention of the first SSRI, Zimelidine, that he developed in the 1970s and was first sold in 1982. Phil McGraw got a TV show in 2002.

        • Careless says:

          Causality is especially complicated when you’re unclear on the order in which events took place

    • HeelBearCub says:

      This is a no-true-Scotsman argument.

      And it is also basically irrelevant. Scott Alexander is, right here, supporting the statements and he is a practicing psychiatrist.

      Heck, Psychiatry does believe in treating depression using drugs that affect brain chemistry. You don’t really have to go any deeper than that to find support for the “chemical imbalance” position.

      And if you look hard enough, you could probably find clinicians who have actually used the phrase “depression is caused by low-serotonin” as a different short-hand way of simplifying for their patient.

      None of which makes the anti-Psychiatry positiin correct.

  17. Salem says:

    depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?

    Rational choice is a strange term here, but how about just ordinary psychology and incentives? Depression makes people behave differently, but I promise you that when I was depressed, I’d have jumped out of my bed if you’d set it on fire. I really do think depression is a kind of extreme laziness (although note that laziness itself is kinda mysterious, and must also ultimately result from “chemical imbalance”) in the sense that ordinary pressures still work on depressed people, but they have to be massively amped up in threat and urgency.

    I think its both dishonest and unhelpful to model depression as closer to a seizure than to regular psychology.

    • FeepingCreature says:

      If my legs were broken and you set the bed on fire I’d still jump out. I just want to note that.

    • Annms says:

      Is it helpful or kind to apply a morally condemnatory label to depression?

      • Could you give examples of behavior where it is helpful and kind to apply morally condemnatory labels to them?

        • Izaak Weiss says:

          I can’t think of an example that satisfies the conditions as you stated them, which seems to me a pretty convincing argument against any form of morally condemnatory labels, rather than an argument for applying them to people with depression.

          Then again, maybe that’s what you’re going for; I couldn’t tell.

      • Salem says:

        I think you and I are probably separated by a vast inferential gulf. Suffice to say that I think that the best way to solve depression is to understand it accurately, rather than sugar-coat things. As for kindness – I think much of what gets called “kind” is anything but. I don’t see anything at all kind in pretending that depressed people have no agency or in running away from accurate understanding of the problem because of an ideological fear of seeming judgemental.

        • Deiseach says:

          Okay, I will take it that you mean “Instead of leaving your brother Jim to sit in his pyjamas for an entire week, go over and pull him out of bed or off the sofa and shove him into the shower and chivvy him into getting dressed and going out for a walk with you”.

          And yes, that’ll probably help. But yelling at Jim about how he’s a lazy bum and has no reason to be ‘depressed’ because he has a good job, his family love him, he’s not in debt, he has no life-threatening illness, and think of all the people who are starving in Africa, so he makes you sick, you’re ashamed of him, stop pretending you’re special, get up off your lazy backside –

          – do you really think depressed people don’t think that for themselves? That when I was sitting at my desk crying, I wasn’t thinking “Why the hell am I doing this? There’s no reason! Nothing is wrong! I like my job and my work colleagues!”

          That didn’t stop the crying. My boss standing over me yelling about how I was worthless and should be ashamed of myself for being a whiny little bitch wouldn’t have stopped it either.

          • HeelBearCub says:

            This.

            My Dad, who is like me in many ways, gets far more done than I. He does this by being in a constant state of self-moral panic. He tried that with me as a young lad and it has mostly ended up with me hating myself and near catatonic in areas where I must rely on internal agency.

            As someone who has depression and ADD, my psychiatrist made the astute observation that some people are just built to be firefighters. I’m great in a work crisis. I get shit done and can go non-stop for days.

            Let that pressure off, and I can be damn near useless . Moral panic is not helpful, only actual panic will do.

    • yli says:

      The common mistake is in thinking that because extreme pressure would work, it’s okay to torment the person with predictably useless moderate pressure.

  18. PGD says:

    It would be nice if Scott engaged more fully with the arguments being made by critics here. For example, in his book ‘Mad in America’ Robert Whitaker digs up evidence that psychiatrists have systematically minimized the side effects of psychiatric drugs and systemically repressed evidence that simple physical interventions like exercise and social interventions like therapeutic communities can have effects on mental illness that are on net far more beneficial than the psychiatric interventions favored at the time.

    http://www.madinamerica.com/source-documents/

    This kind of thing is more on point to the full set of claims that are being made about what psychiatry was doing promoting a ‘chemical imbalance’ view.

    Also, I found this paragraph kind of weird:

    “I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala. I think large-scale variations in crime rate are mostly attributable to environmental levels of lead and probably other chemicals. It would be really weird if depression were the one area where we could always count on the inside view not to lead us astray.”

    First, genetic determination of behavior, or determination by external contaminants, is actually a totally different issue than whether depression is best thought of as a ‘chemical imbalance’ or e.g. a breakdown in social support systems. Anything, including genetics but also including a breakdown in social support systems or a failure of willpower or bad parenting, will show up as a physical change in the brain in some way. The ‘chemical imbalance’ question is whether the best way to approach the issue is by tinkering directly with chemicals in the brain or by some modification of external environment or self-understanding. That is not about genetics.

    Second, this is a matter for another thread, but I think it’s a little bit nutty to claim that peoples’ political beliefs are genetically determined and such a claim bespeaks a fundamental incomprehension of how the social and genetic interact. Partially inborn personality traits (e.g. having a bad temper) may tend to get people to respond to currently dominant social structures/social cues the same way, but that doesn’t mean that changing the social setting wouldn’t have a massive and transformative effect on political beliefs. Some of the same kind of interaction issues arise in thinking about depression. Someone who wants to isolate genetics from social interaction is going to have a hard time with psychology in general it seems to me.

    • Shieldfoss says:

      I think it’s a little bit nutty to claim that peoples’ political beliefs are genetically determined

      You must be new here. There’s a long post – with citations – somewhere in the archive or, possibly, on the old site.

    • Corwin says:

      To a point. 60 to 80% heritable, with studies conducted on twins separated at birth.

      • vV_Vv says:

        To a point. 60 to 80% heritable, with studies conducted on twins separated at birth.

        Raised in different countries?

        • Anonymous says:

          I think you might be talking over each others heads.

          View A: “Politics is obviously socially determined, because which (genetically influenced) traits are favored by a given party at a given time is part of society.”

          View B: “Politics is genetic because twins separated at birth have a degree of correlation in political beliefs.”

          It’s like asking if violence is social or genetic. Aggression is largely genetic, and society can shape how that aggression is expressed. View A would call violence social, and view B would call it genetic, but I would be surprised if either disagreed on any particular matter of fact.

          • PGD says:

            exactly, thank you. The claim that political *beliefs* are genetic is pretty obviously false. The claim that e.g. strength of political partisanship, or the level of belligerence with which political beliefs are expressed, has a heritable component in a particular society is much more plausible, but all that is being claimed there is that personality has a genetic component, which we know. Society shapes how political partisanship plays out and on what issues it focuses, but a general tendency to be belligerent is a personality trait. Even that will express itself differently depending on what is socially acceptable and encouraged.

            Note that the article Scott linked in the OP found only that strength of partisanship was heritable, vs. actual beliefs being heritable.

            My general point was also that if you don’t separate the genetic components of personality (inborn) from how it is expressed (socially mediated) you are likely to misunderstand a lot about psychology, which involves a huge element of social mediation.

          • Alexander Stanislaw says:

            @PGD

            The claim that political *beliefs* are genetic is pretty obviously false. The claim that e.g. strength of political partisanship, or the level of belligerence with which political beliefs are expressed, has a heritable component in a particular society is much more plausible

            Nope, individual political beliefs are also heritable. Less so than political partisanship (only about 0.3 to 0.5 for any individual belief as opposed to 0.6 for just partisanship) but its still large.

          • Douglas Knight says:

            Your link is broken. correct link

          • vV_Vv says:

            It is indeed plausible that there is a genetic component that influences political beliefs, but a statement like “people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala” is at best misleading without a big disclaimer saying “all other things being (mostly) equal”.

            The range of political beliefs that have been held by significant groups of people throughout history is too vast, and the speed at which populations, or even individual persons, can change their political beliefs is too fast for political beliefs to be mostly genetically-determined traits.

      • Protagoras says:

        Perhaps these particular studies are unusually good, but my general understanding is that because twins being raised apart is actually quite rare (twins are, of course, not all that common to begin with), there are many twin studies with very lax, dubious standards for what counts as “raised apart” in order to ensure that they have enough subjects.

        • Douglas Knight says:

          Separated twins are so rare that most studies don’t use them. Most compare identical to fraternal twins (like the study Scott cited) or adoption of non-twins. And yet all three methodologies produce the same answer. So maybe separated twin studies aren’t that bad. And maybe the complaints are excuses made by people who don’t like the answers.

    • Salem says:

      Psychiatrists aren’t suppressing any information. For example, all psychiatrists know and acknowledge that exercise helps with depression. But if you have a severely depressed patient, it’s just cruel to say “Yeah, the problem is you need to take more exercise. Go do that.” They won’t be able to do such a regime, precisely because they are depressed. A large part of the idea behind prescription of antidepressants is that they will cause enough uptick in mood that the patient will be able to take exercise, socialise, etc, sufficiently that those activities will further raise the mood, and so on in a virtuous cycle back to normality.

      So unless you have some mechanism to get depressed people to exercise, saying that it would help is not helpful. It’s not impossible – chasing someone around the park with a cattle prod would work – but no-one has come up with a good regimen yet.

      Psychiatrists are not hiding or ignoring your information, they have simply considered and rejected it.

      • >So unless you have some mechanism to get depressed people to exercise, saying that it would help is not helpful. It’s not impossible – chasing someone around the park with a cattle prod would work – but no-one has come up with a good regimen yet.

        Serious but silly sounding question – have we tried chasing people around with cattle prods? Like, literally giving people small pain stimuli unless they do an exercise?

        • fubarobfusco says:

          This treatment would seem to assume that the patient wants to not experience pain.

          • Deiseach says:

            Or that the small pain stimuli are more painful than the exercise; having your muscles seize up the day after more-than-normal activity so you can’t walk, for instance, if you need to be able to walk for your job may mean that the person will grit their teeth and ignore the pain stimuli today for the benefit of tomorrow.

            If you’re going to hurt people a lot unless they exercise, you could put some of that effort into helping them exercise instead?

          • Anonymous says:

            Well, we could run them around to the point where they’re in pain but not literally unable to walk. The amount of pain after exercising is variable based on fitness and amount of exercise done.

          • Nornagest says:

            I’m not going to say that literally no coaches or personal trainers will tell you to run past your limits to the point where you can’t walk the next day, but I am willing to say that one who tells you that should be fired. You should be shooting for mildly to moderately sore at the most, and some methodologies don’t even go that far.

            That is, of course, going to be harder for the guy with the cattle prod to discern, especially if there’s a large gap in physical fitness. So it’s important that our cattle prodders be properly credentialed.

        • Matthew says:

          Less silly questions:

          1) (Assuming you have space to do so while maintaining confidentiality) Why don’t we conduct walking meetings with pscyhologists/psychiatrists, instead of having the patient sit down or lay on a couch?

          2) (Assuming you could actually convince insurance to pay for it) Would it not be beneficial for many depressed people for a psychiatrist to prescribe a series of home visits from a personal trainer, who’s there not to make the person become strong, but just to provide the external motivation to stay in motion?

          • Izaak Weiss says:

            Well those are fucking great ideas. If my counselor had just a treadmill in her office, and I could walk while we talked, that would be super beneficial. Not in the least because I think better while walking.

    • Deiseach says:

      social interventions like therapeutic communities

      I’ve been recommended counselling and I’ve rejected it because I don’t think it will help. There’s a mental health awareness support group that meets in my area regularly and I could roll up to the door and take part in a group therapy session – but I would rather be set on fire than talk to strangers: even the idea of sitting there and saying nothing is impossible because I also have agoraphobia/social anxiety; I had to leave a pageant in my brother-in-law’s church for the simple reason I couldn’t stand being in the middle of a large group of people, and I can assure you that within ten minutes of attending a group session, no matter how sympathetic the other people or how they had shared similar experiences to mine, I’d be jumping up and heading out the door because simply sitting down in a group of strangers would shred my nerves too much.

      So social interventions are not going to cut it for me. I am trying a couple of things, but the crucial point here is that what I am willing (and able) to try are all solitary, private actions I can take within my own home, not reliant on going out and mixing with people or interacting socially.

      Medication, frankly, is going to be more help to the likes of me, because although therapy and counselling probably is very useful, I can’t make use of it for various reasons to do with personality and the like.

      • houseboatonstyx says:

        [ content note: redundancy intentional ]

        As addition to your much-valued presence here, perhaps some readers here might suggest additional online groups with the same virtues.

        • Deiseach says:

          Coming on here crying on your shoulders really does help me a great deal. Thank you all for that.

          It’s a Catch-22 situation; one of the coping strategies for dealing with depression is overcoming social isolation and trying to get out and interact with people, but my other family-heritage mental blips mean that I can’t go out and meet people and mix with them, e.g. at work we have to attend meetings in The City, so I’ve been offered lifts down and back by co-workers who also have to go to meetings there, which I’ve refused; I prefer to travel on public transport for the simple reason that I can’t face the prospect of forty minutes in a car with people who I get on perfectly fine with in a work situation, but when it would be two of us in an enclosed space and I’d have to make conversation (in reality, sit there in tense and anxious silence) – no.

          So depression on the one hand and agoraphobia on the other get me coming and going.

      • Along the same lines as another comment, social interaction online is simultaneously “solitary, private” and the opposite. My wife and our children are all much more shy than I am, and do a lot of their social interaction online. It seems like a reasonable solution, a way in which you might be able to get the benefits of a “therapeutic community” (broadly defined) without triggering your particular problems.

        • Deiseach says:

          That’s true. You people know a heck of a lot more about the inside of my head than my own sister, and that’s not because I don’t get on with my sister.

          It’s way easier to put things up on screen than it is to tell it to someone face-to-face (that’s why I prefer the old-fashioned confession boxes with the screens rather than the new-fangled ‘face-to-face’ rooms where it’s you and the priest sitting looking at each other).

        • PGD says:

          Isn’t there a lot of research that finds intensity of online social interaction correlates with depression? It’s unclear which direction the causation is running (obviously it’s possible that people who can’t get out of the house because of depression spend more time online), but I could see a vicious cycle of sorts operating.

    • Peter says:

      Scott: “I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala.”

      PGD: “a little bit nutty to claim that peoples’ political beliefs are genetically determined”

      I don’t think Scott is claiming that political beliefs are genetically determined. Influenced, yes, not determined. AFAICT “highly genetically loaded” means “variation in X, within context, is highly correlated with genetic variation”. Which I don’t see as being incompatible with the contents of your latter paragraph.

  19. Grumpus says:

    I don’t have anything substantive to say, but I just wanted to try this whole “being supportive” thing and say that I think this post is very good and definitely necessary. Sorry for the excessive grumping last time, y’all.

  20. Deiseach says:

    Re: diagnosing depression, if the criteria are as quoted:

    To meet the official criteria, they had to have experienced a major depressive episode — defined as a debilitating depressed mood or loss of interest in daily activities for at least two consistent weeks — in the past twelve months.

    Then, if I were being asked that to assess whether or not I really was depressed (rather than being a bit down because of relationship problems or work stress), I would have to answer that “I don’t know”.

    How do I differentiate between how I felt in the past fortnight versus how I’ve been feeling in the past forty years? Take one example: I’ve loved reading all my life. I joined the library the minute I was able (and that involved a remarkable amount of hassle for a small town library). I even wrapped up and walked over the town during a snowstorm (or what passes for one in Ireland, which is a ‘snow sprinkle’ elsewhere) to go to the library to return my books and get new ones out.

    And now I’ve let my membership in the library lapse with about eight years. I have books on Kindle that I haven’t read – a book by one of my favourite authors, that I was anticipating its release, is sitting there with a month and I haven’t looked at it. This is indeed a loss of interest in an activity I formerly enjoyed, but I can’t pin it down to “yeah, this has been going on for the past two weeks where it didn’t happen before”.

    And what if the assessment takes place during the good times, because there are peaks and valleys with depression? If I was assessed during the time when I broke down and went to my GP, I’d be classed as depressed. If I was assessed now, when I’m feeling a bit better and can be functional again, I’d probably be classed as “not really depressed”. And then what happens, in five or eight weeks when it gets bad again and I go back to my doctor? They look at my assessment, see I’m not clinically depressed by the official criteria at the time of assessment, and I get told it’s more or less all in my mind and pull myself together.
    I really do understand why the chemical imbalance theory appealed so much to the first generation of psychiatrists who heard it: it meant that now they could do something for patients who had, on the face of it, no objective reason to be depressed (or other problems). Where the only choices were “it’s all your imagination” versus “it’s a physical illness”. Where no amount of chivvying to pull yourself together worked. And now here were drugs, and they worked, and a theory for why the drugs worked.

    Now illnesses were physical and treatable and you were no longer dependent on the talking cure, you could be a real doctor (I think this, too, lies at the root of wanting to keep psychologists from getting the power to prescribe). Now you had tools to help your patients like the bright new world of the “magic bullet” that was going to cure all physical disease!

    Having to say “We don’t really know what causes it or why the drugs work, we’re just prescribing them on faith and asking you to take them on the chance they might work for you, and if this one doesn’t we have to play hit-and-miss with dosages and different drugs” isn’t very scientific-sounding 🙂

    • Deiseach says:

      I’m banging on about “the past two weeks” because that’s the period mentioned in the assessment questionnaire:

      Over the last two weeks, how often have you been bothered by any of the following problems?
      – Little interest or pleasure in doing things?
      – Feeling down, depressed, or hopeless?
      – Trouble falling or staying asleep, or sleeping too much?
      – Feeling tired or having little energy?
      – Poor appetite or overeating?
      – Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
      – Trouble concentrating on things, such as reading the newspaper or watching television?
      – Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
      – Thoughts that you would be better off dead, or of hurting yourself in some way?

      Which, if I were going to answer them, would be:
      – It’s been particularly bad the past three months or so, but I can’t pick out the past fortnight as worse than usual
      – Try “for years and years” rather than “two weeks”, but it waxes and wanes
      – Always had trouble falling asleep. Have done the “sleeping 48 hours straight, only getting up to go to the bathroom” thing, but not for a long while now. Sleep has been poor and unrefreshing for six months or so.
      – Past few years, but then again, my overall physical health suddenly declined about five years ago, so whether this is due to depression or physical decrepitude I have no idea.
      – Overeating? I’m morbidly obese, work it out for yourself!
      – All my life. Not an exaggeration. I’ve felt like a failure since I was eight and started crying in 2nd Class because I couldn’t understand the maths that everyone else seemed to have no trouble with.
      – Haven’t read a newspaper in years; get my news off newsfeeds and Google News. Never watched TV regularly; in recent times, only following one particular show anyway regularly. Never watched the shows everyone in the country was or is watching, e.g. Love/Hate, Big Brother, X Factor, etc.
      – I move at about the rate of the average sloth. No-one has ever commented on it, though. I do fidget, but again, no-one has ever commented on it.
      – No self-harming, but thinking about death for a long time. Have not been actively thinking about suicide since I was twelve, though. Do feel there is no rational, objective reason for me to be alive.

      So – am I depressed or not? None of this has cropped up in the past two weeks, I don’t feel all of these all the time, some times are better than others, and I can’t pick out any experience to go “Yes, I used to be fine, but now I feel like this” because I’ve always – or at least, since puberty – ‘felt like this’.

      • Anonymous says:

        Depression scales that ask about *changes* in behavior are a problem. They miss dysthymia or symptoms that may have existed about as long as the person has been sentient. You’d think the mental health community would have caught on by this point and fixed it.

        • Deiseach says:

          I think they’re good for diagnosis if it’s sudden-onset, with a definable trigger situation, or if it’s caught early. But I agree: they’re pretty much useless when someone finally can’t cope any more, and comes in after months/years/decades of feeling depressed. There isn’t any sudden change or big difference between how you’re feeling/functioning this week, last week, six months ago.

        • HeelBearCub says:

          @Anonymous: But the bit that Deiseach quoted doesn’t ask about changes. It asks whether these things are bothering him “right now”, where “right now” isn’t “the moment I am in this office filling out this questionnaire” but “this moment in my life”.

          @Deiseach: It sounds to me like your answer to all those questions (except for the self-harm one) is “all/most of the time”. All or most of the time in the last two weeks you have been bothered by those problems. Just because it was all/most of the time before the last two weeks doesn’t alleviate the pain you have been feeling in the last two weeks.

    • Xenophon says:

      Having to say “We don’t really know what causes it or why the drugs work, we’re just prescribing them on faith and asking you to take them on the chance they might work for you, and if this one doesn’t we have to play hit-and-miss with dosages and different drugs” isn’t very scientific-sounding 🙂

      It’s interesting to note that the above quote is a darned good paraphrase of what my medical head-shrinker has said to me many times. He’s also been quite clear about side-effects, and about the importance of remaining aware of the trade-offs between the benefits of whatever I’m taking vs. the side-effects there-of.
      [edited for grammar]

  21. onyomi says:

    I think a large proportion of the problem can be blamed on patients’ expectations about medicine (which might, in turn be traced way back to how doctors and medical researchers present themselves to the public, but…).

    That is, ever since the great successes of the microscope, the vaccine, and the antibiotic, we’ve had a very reassuring vision of medicine as working like this:

    Scientific, objective test to figure out what’s wrong–>carefully chosen treatment to address what we know to be wrong–>cure

    That is, you go to the doctor, they look in your throat, they take some urine or some blood, and they call you back and say, “yep, test shows you have strep. Take these strep-killing pills for a week and you’ll be fine.”

    Of course, there are many problems that aren’t this simple, but on some level we still want it to work like that.

    What we DON’T want to hear is, “we’re not exactly sure what’s wrong with you, but it probably involves a very complex interplay of environmental and genetic factors. We’re not exactly sure how this pill works, but it seems like a fairly high percentage of people with symptoms similar to yours have improved by taking it. Also, 10% of the time it makes you twitch uncontrollably, though we’re not sure why, and have no way of knowing in advance whether you’ll be in that 10%.”

    This subjectively feels very unscientific and not reassuring, and doctors know this, and so they don’t usually present it to patients like this. What I think the complaints about “chemical balance” boil down to is people saying “psychiatrists acted like they knew what they were talking about, but in reality, they were kind of stabbing in the dark.”

    I remember the first time I saw a psychiatrist many years ago asking him why he couldn’t just run a test to figure out whether I had low serotonin or whatever. I imagined my mental health like a bunch of little bars one could easily see on a chart and point and say “ah ha! too much norepinephrine and acetylcholine, not enough gaba and serotonin! Let’s just adjust these knobs here…”

    Of course it isn’t so simple, but because of the way other aspects of medicine work, that’s how we want and, on some level, expect it to be with mental health as well.

    • houseboatonstyx says:

      What we DON’T want to hear is, “we’re not exactly sure what’s wrong with you, but it probably involves a very complex interplay of environmental and genetic factors. We’re not exactly sure how this pill works, but it seems like a fairly high percentage of people with symptoms similar to yours have improved by taking it. Also, 10% of the time it makes you twitch uncontrollably, though we’re not sure why, and have no way of knowing in advance whether you’ll be in that 10%.”

      This subjectively feels very unscientific and not reassuring [….]

      To me it feels very reassuring. It shows that the doctor is honest, and carries the meta-message: You are the decider. If something begins that might be a side-effect (look them up*) or if it doesn’t seem to help, look for something else. The drug companies’ usual “Give it six months” is not something you really have to do.

      * and the instructions for discontinuing

      • onyomi says:

        @HouseboatonStyx,

        I sort of agree with you in that I like it when doctors are frank and honest with me, but I also think it would be very UNreassuring for a doctor to say “well, you could try this med or that med or that med, or no meds? All up to you?” which I have also had doctors say to me. This makes me think, “so why am I seeing you? Just because you have the power to prescribe drugs? Aren’t you supposed to give me a more informed opinion than I could form on my own with WebMD?”

        Re. the fake certainty: though it would obviously be wildly unethical, I would predict that, if psychiatrists could *pretend* like it were possible to measure neurotransmitter levels with a simple blood test, and they then prescribed patient meds “on the basis” of those fake tests (but actually in accordance with current criteria), people would generally have better outcomes due to more faith that what they were taking was what they actually needed.

        • vV_Vv says:

          Re. the fake certainty: though it would obviously be wildly unethical, I would predict that, if psychiatrists could *pretend* like it were possible to measure neurotransmitter levels with a simple blood test, and they then prescribed patient meds “on the basis” of those fake tests (but actually in accordance with current criteria), people would generally have better outcomes due to more faith that what they were taking was what they actually needed.

          Until the lie was uncovered and the whole psychiatric profession discredited.

          • onyomi says:

            I’m not seriously proposing this as something that could ever work; I’m just making a point about the expectations of patients re. medicine.

        • houseboatonstyx says:

          I sort of agree with you in that I like it when doctors are frank and honest with me, but I also think it would be very UNreassuring for a doctor to say “well, you could try this med or that med or that med, or no meds? All up to you?” which I have also had doctors say to me.

          That’s why it’s a meta-message. 😉

          I considered “[we can] look for something else” or “[I can find] something else [for you]”. Or, after somehow stepping out of character, “look for something else, [and if necessary look for some other doctor]”.

        • Princess Stargirl says:

          “but I also think it would be very UNreassuring for a doctor to say “well, you could try this med or that med or that med, or no meds? All up to you?” which I have also had doctors say to me. This makes me think, “so why am I seeing you? Just because you have the power to prescribe drugs? Aren’t you supposed to give me a more informed opinion than I could form on my own with WebMD?” ”

          If a doctor is prescribing a normal medication and not doing more involved treatment than webMD is almost surely as good as a doctor if not better. At least assuming you do not have any unusual conditions which could interact poorly with the drugs.

          One cannot really use general knowledge of the human body to decide on a drug. The way to decide which drug to use is through reviewing studies. And this does not require any medical school.

          So I would strongly prefer the doctor just be honest. Though I understand why they are not.

      • Izaak Weiss says:

        I agree with you, that’s exactly what I want to hear. And maybe it’s just me being lucky, but that’s also exactly what I hear from my doctor.

    • Doug S. says:

      I remember the first time I saw a psychiatrist many years ago asking him why he couldn’t just run a test to figure out whether I had low serotonin or whatever. I imagined my mental health like a bunch of little bars one could easily see on a chart and point and say “ah ha! too much norepinephrine and acetylcholine, not enough gaba and serotonin! Let’s just adjust these knobs here…”

      [missing the point?]
      The answer is that they can’t actually do those kinds of measurements on your brain without killing you in the process. 🙁
      [/missing the point?]

      • onyomi says:

        Yes, I understand that now, but they didn’t explain that in such clear terms to me then.

        More importantly, I’m saying that, absent significant experience with psychiatry, the general public probably thinks psychiatry either is, or else should be more like “regular” medicine, where you get a test, a diagnosis, and a treatment.

        Though the general public probably overestimates the precision of general internal medicine as well, I think they vastly overestimate how much experts understand and can accurately measure what’s going on in the brain, and that many psychiatrists, not wanting to sound like quacks to those people, act like they are doing something more precise than they really are.

      • Deiseach says:

        Yes, but people are used to blood tests where a sample is drawn and then the results come back and the doctor goes “Ah yeah, by the levels of PDG in your blood, your thyroid is banjaxed, here’s the tablets you need for that” so we expect that the same can be done for the brain.

        Until you’re told that “Sorry, we’d have to cut out your brain and mash it up to find out those levels”, you don’t know any better.

    • Paul Torek says:

      Your hypotheses do seem to explain a lot.

    • Scott Alexander says:

      Unfortunately, there are now scam services that will do exactly this. In case anyone was planning on getting one of these, measuring serotonin in your bloodstream (or whatever) is worse than useless – it’ll just pick up whatever serotonergic things are going on in your gut. If you want a decent serotonin measurement, you’re going to have to go the way of the poor macaques in the study above!

  22. vV_Vv says:

    I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala. I think large-scale variations in crime rate are mostly attributable to environmental levels of lead and probably other chemicals. It would be really weird if depression were the one area where we could always count on the inside view not to lead us astray.

    Yeah, that’s why we all still support oligarchic city-states as the preferred form of social organization. I didn’t realize that Neo-reaction was so popular!
    Also, “lead pollution made me do it” is a totally valid legal defense. 🙂

    I mean, seriously, genetic and environmental factors may have an effect on political and law abidance behaviors by influencing things like altruistic preferences, risk-aversion, time-discounting, g-factor, specific cognitive biases, and whatnot, but this doesn’t invalidate the intutive model of these behaviors in terms of choice by boundedly rational agents who respond to incentives.

    I don’t know much about depression, but is there evidence that yelling at them to get out of bed and pull themselves by the bootstraps, or better, make them live in a society where they can actually starve if they don’t pull themselves by the bootstraps, does not work in most cases?

    • Deiseach says:

      make them live in a society where they can actually starve if they don’t pull themselves by the bootstraps

      Suicidal ideation is part of depression. Lying down and starving to death is not that huge of a threat/incentive when you have no reason to try and stay alive.

      And if we just use tasers on those fakers who claim to need wheelchairs, you’ll soon see them jerking around and moving away, even if they have to crawl! So there’s no reason they can’t go and get work down the coal mines!

      • vV_Vv says:

        Hunger is particularly unpleasant. Depressed people often say that they don’t feel strong emotions. I suppose this is difficult if you are actually starving.

        • Deiseach says:

          I have gone all day without drinking a drop of water, ignoring thirst signals, because I couldn’t muster the energy to get out of bed even the short distance to the bathroom to stick my head under the tap.

          Talking about “sleeping excessively” isn’t really what is going on; it’s not like normal sleep, it’s like unconsciousness or anaesthesia. It drugs you and drags you down; it’s like being hit over the head so all you can do is fall back ‘asleep’ and you’re tired no matter how long you’ve been sleeping.

          It scared me, to be honest; fourteen hours just whizzed by in a blur and I had no idea it was that long. I had even longer periods of ‘sleep’ at later times; it hasn’t happened in a good few years now.

          It’d be perfectly possible to starve (really die of thirst, which would happen first) by depression.

          • Anonymous says:

            Deiseach, did your sleep issue resemble anything like this?

          • vV_Vv says:

            But you knew that you just needed to walk a few meters and open the tap to get some water.

            Would you still have lied in bed if you knew that you had to walk kilometers to a well to fetch water and then boil it before it was safe to drink it?

            Maybe in undeveloped societies people with less than optimal mental health just die or fail to reproduce.
            Maybe human mental health is very frail at the genetic level, so much that random combination of usual alleles can cause several illness, and only strong selective pressure can prevent mental illness from becoming widespread.

            But the increases incidence of mental illness that follows modernization seems to be too sudden to be explanined by genetic effects alone.

          • onyomi says:

            I do think there is something to the idea of depression as a “first-world problem,” though I’m sure it’s also a matter, in many cases of it going undiagnosed in the third world.

            Besides the fact that third world conditions (being outside a lot, not using a lot of modern conveniences, tight-knit social groups, etc.) are probably paradoxically conducive to mental health when you’re not suffering a plague or getting stabbed, there does seem to be something about the immediacy of fighting for your life or struggling to figure out where your next meal will come from that makes it harder to get depressed.

            I see it as:
            1, human happiness has set points that aren’t easy to move way up or down just because we have a bunch of technology any cave man would be ecstatic to have. Let him use the cell phone for a month and he’ll start taking it for granted and being miserable when it’s broken just like us.

            2, The human brain is basically a problem-solving machine. When immediate problems like where to find food are solved it moves on to bigger problems, but it never stops trying to solve problems. But which problem do you have a better chance of solving: “I need food and shelter” or “the universe is empty and meaningless”?

            That said, I’m sure there are many very miserable people in the third world and, as David Friedman mentioned in another thread, it’s probably hard to fathom the boredom involved in premodern rural life, but I do think there is something to this nonetheless.

            I can see it with myself: I’m more prone to mental health problems when I’m not busy.

          • Paul Torek says:

            onyomi said,

            I do think there is something to the idea of depression as a “first-world problem,” though I’m sure it’s also a matter, in many cases of it going undiagnosed in the third world.

            Doubtful. That’s what the World Health Organization thought about schizophrenia, which their first study found was also more a first-world problem. So they re-did the study, carefully controlling for such issues. Still, the rate of recovery from schizophrenia was very substantially better (over half, in five years) in the less developed countries. Even in the absence, in many cases, of any formal treatment.

            Rates of incidence of schizophrenia varied by country, but not so much by Less/More Developed.

        • onyomi says:

          On the other hand, I find that fasting (consuming nothing but water for days on end) is great for my mental health.

          • Devilbunny says:

            Out of curiosity, have you ever tried a ketogenic diet?

          • onyomi says:

            Yes, but it did not have the same effect. Also, I don’t so much feel better during the fast as after, so it’s not like carbs are making me depressed, though I have heard the ketogenic diet can be great for people with seizure disorders, and I must admit I have never tried it for an extended period.

            Basically, I consider the ketogenic diet to be wimpy fasting. It puts your body into the same “mode” as fasting, which is one of low energy and weight loss, but is not as hard for some to maintain. For me, I’m going to have no energy if I eat no carbs regardless, so I might as well just go all the way and fast.

            My problem with things like Atkins long term is that they seem to be trying to take what is a beneficial short-term state (i. e. the fasting response) and make it work long-term, when that is not its function. Fasting takes the opportunity of limited or no food to use up old food stores, clear out old junk, rest and heal, but one is not meant to be in fasting mode all the time. For energy, I think, carbs are necessary, and I also worry about the heart health of people living on bacon and eggs all the time (though I do love meat and fat).

    • Leo says:

      For the starvation condition, there’s massive anecdotal evidence (e.g. “When I was depressed I just stopped eating for days on end”; “I couldn’t cook, so I ate raw dried beans”; “I lost my job and moved into a homeless shelter”) but it seems hard to run a study ethically.

      For the yelling condition, well, it seems to have been tried on more depressives than not.

      • vV_Vv says:

        “I lost my job and moved into a homeless shelter”

        What if there is no homeless shelter?

        I agree that it is probably not possible to ethically conduct randomized controlled trials, but observational studies across different societies could be performed.

        Isn’t depression a first-world disease?

        • Alexander Stanislaw says:

          Isn’t depression a first-world disease?

          It is not

        • Ptoliporthos says:

          I’m pretty sure depression happened in the second world too, Soviets just tended to self-medicate by drinking alcohols (methyl, ethyl, isopropyl, butyl, etc.) so Gorbachev called it ‘alcoholism’ instead.

          To the extent depression occurs in the third world, how much of it might be masked by a first-worlder’s willingness to regard the symptoms of depression as a normal response to poorer material conditions that a denizen of the third world might not think of as abnormally harsh?

          • vV_Vv says:

            I’m pretty sure depression happened in the second world too, Soviets just tended to self-medicate by drinking alcohols (methyl, ethyl, isopropyl, butyl, etc.) so Gorbachev called it ‘alcoholism’ instead.

            According to Wikipedia, the last major Soviet famine occurred in 1947. Was alcoholism common in the pre-WW2 era?

            I suppose that the Soviet society mainly differed from Western ones in that it was less meritocratic and personal effort was therefore perceived to be less meaningful:
            you were unlikely to starve after 1947, but the quality of your life largely dependend on how much some unelected government officers screwed up. You had little chance of improving it by hard work, and indeed work largely consisted of filling a quota set by bureaucrats who had little idea of what they were doing, at least as far as you could perceive.
            If depression is mainly caused by lack of high stakes in your daily personal life, then the Soviet system looks like the perfect receipe for it.

            (Disclaimer: I’m a Western European born in the 80s, hence there is a chance that I don’t know what I’m talking about. Ex-tovarishes please feel free to correct me.)

        • US says:

          “Depression is the most common mental health disorder in communities, and is among the leading causes of disability across the world: It is estimated to affect 350 million people worldwide [12]; in 1990, it was the fourth most common cause of loss of DALYs worldwide [13], and by 2020, it is estimated to become the second common cause [14].”

          A quote from the book A Systematic Review of Key Issues in Public Health, by Boccia, Villari and Ricciardi. There’s a lot of room for argument here given the uncertainties involved, but the authors of that chapter would certainly not agree with the view that depression is a first-world disease. Unfortunately there’s no specific geographic breakdown in the chapter, and I’m too lazy to look up the primary sources.

          For what it’s worth, I believe it’s quite common in textbooks on diagnostics to remark upon cultural differences in terms of the manifestation/expression of symptoms of depression (at least I’ve seen this a couple of times); for example because in some cultures such a diagnosis is a lot more acceptable than it is in others, presumably leading to, among other things, issues with under-reporting.

          On a related note:

          “Globally, the most common methods of suicide are ingestion of pesticides, the use of firearms, and medication overdose. In developing countries, particularly in rural areas, ingestion of pesticides is the main method of suicide. An estimated 30% of global suicide deaths are believed to involve ingestion of pesticide. Although reliable data on suicide attempts in developing countries are scarce, the gender disparity in suicide behaviour that is so striking in developed countries is less dramatic in developing countries. This may partially be accounted for by the high case fatality associated with pesticide ingestion. Where pesticide poisoning is the most common method of choice, survival following an attempt is unlikely. […] In contrast to the relative low toxicity of common substances used in suicide attempts in the west, case fatality following ingestion of commonly used pesticides – paraquat and aluminum phosphide – is estimated to be over 70%. Further, the window for successful intervention in pesticide poisoning is very short and in many developed countries lack of access to and availability of appropriate medical care services, antidotes to pesticide poisoning, and properly trained health professionals to manage pesticide poisoning is a significant barrier to potential life-saving treatments.”

          From Suicide Risk Management – A Manual for Health Professionals, by Chehil and Kutcher. I know suicide and depression are different topics, but the quote seemed relevant to me given the question posed.

          • PGD says:

            The World Health Organization cross-national surveys of mental disorders (performed using a common survey instrument with training surveyors) find huge differences in the prevalance of mental disorders across countries:

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039289/

            The US pretty much blows every other country away in terms of the amount of mood and (especially) anxiety disorders.

          • US says:

            Thanks for the link PGD.

            My assumption was that prevalence would be higher in the US and Western Europe and lower elsewhere (I think they state as much in the coverage of the first book I allude to above, however I can’t remember and I don’t care enough to look it up now), but it seems the US numbers are a bit higher than the European numbers, though mostly as you say for the anxiety disorders – actually the French lifetime prevalence of mood disorders is comparable to the US prevalence, as is New Zealand’s, according to those numbers, though it seems the US 12-month-data are somewhat higher than the rest.

            If you take the Chinese 12-month mood disorder prevalence at face value and multiply it with ~4,1 or so to take into account the larger population, there are almost as many Chinese people with mood disorders as there are Americans with mood disorders (1,9 % of 1.35 billion, vs 9,7 % of 320 million for the US (prevalence is presumably calculated as % of adults or whatever, but I highly doubt this changes anything). According to the estimate I provided above in my first comment, there are actually many more depressed humans on Earth than there are Americans alive. Given the context of the discussion – which for my part started out with the question ‘Isn’t depression a first-world disease?’ – I’m not sure I’d agree that “[t]he US pretty much blows every other country away”.

            A related point I did not go into here but which is perhaps worth mentioning is that looking only at clinical depression and similar variables is probably going to leave out a lot of relevant stuff when doing international comparisons like these. Looking at happiness research will add a different piece of the puzzle. A Nigerian or Chinese person may be less likely than an American to be clinically depressed, but most of them aren’t nearly as happy as the Americans – see e.g. the cross-country comparisons at page 22-> here: http://unsdsn.org/wp-content/uploads/2014/02/WorldHappinessReport2013_online.pdf

    • James Picone says:

      I was depressed a while ago, and fairly regularly just didn’t eat for a day. That’s not starving, obviously, and the hunger goes away fairly fast.

      I also didn’t really make any attempt to have any food in the house that I could eat when it felt like a good idea.

      As far as I’m aware this is a pretty common experience – I have a friend who is quite seriously depressed, and he changed his desktop wallpaper to a list of Things he was supposed to do each day. I can’t remember the full list or phrasing, but it was something like:
      – Eat
      – Go outside
      – Sleep

      I suspect in societies that won’t take care of people exhibiting depressive symptoms, people exhibiting depressive symptoms will just die.

    • Paul Torek says:

      I’m fond of “the intutive model of these behaviors in terms of choice by boundedly rational agents who respond to incentives.” But to suggest negative incentives (punishments) seems perverse. Because, in addition to responding to incentives, these people are suffering from a surplus of negative emotions, as a giant factor in their other problems. However, social support, together with rewards for health-improving behavior (and the rewards could consist partly or primarily of further social support), strikes me as a downright excellent approach.

  23. caryatis says:

    “And part of what I’m going on is the stated experience of depressed people themselves.”

    So you quote one person?

    What would actually be interesting or convincing is looking at is the experience of everyone who fits (or has fit) the diagnostic criteria for depression–knowing that those people who don’t embrace the medical model are unlikely to be online blogging about being “depressed” or “disabled.” If you think that having depressive moments isn’t particularly important to your identity or interesting to others, you’re less likely to talk about it.

    • Deiseach says:

      If you think that having depressive moments isn’t particularly important to your identity or interesting to others, you’re less likely to talk about it.

      Today seems to be my “whining for sympathy on the Internet” day, but here goes.

      I don’t see any reason why anyone, even other depressed people, should find it interesting that I am or may be depressed. I don’t make depression a part of my identity; believe me, it’s not some “TB was ever so glamorous in the 19th century, look at all the operas about heroines dying of consumption” notion going on here.

      I’ve said it before: being like this is horrible and I don’t want anyone else to be like this.

      So why am I talking about it here? Because I’ve been trying to cope with it for years, and I can’t do it anymore. Because I’m desperate. Not because I want affirmation or pats on the head or that I’m sympathy-whoring; because I’m looking for help to not be this way anymore.

      And it’s not moments, anymore than you have “moments” of breathing. It’s a constant background. Sometimes things are better and you can get on with things and even at times be happy. Sometimes things are worse, and you find yourself spending the first ten minutes at work crying at your desk for absolutely no reason (and devoutly grateful you’re the first one in to the office so there’s nobody else to see this).

      But it’s always there, to the point where it’s normal. Where it’s not “why am I feeling unhappy or dull or lacking energy” but “what is it like not to want to curl up in a ball and hide? Must be nice, I suppose”.

      Where I manage to get myself out of bed on Monday morning and go to work instead of calling in sick and this is a fucking big deal. To be able one more day to pass for normal. To keep putting one foot in front of the other, until I can’t anymore.

      And then I go on here and whine and moan and ask for advice, because I’m having my mini-mental breakdown and I have no-one else to talk to (no-one I can talk to, physically unable to make myself talk to my family, easier to talk to strangers who are only a bunch of characters on a computer screen).

      I fully realise self-pity is extremely unattractive. I find myself disgusting, going on here and crying about how I’m depressed. But it’s not “Oooh, my Special Snowflake identity”, it’s sheer bloody end of my rope desperation.

      • speedwell says:

        Deiseach, you are saying this for hundreds of people who could say the same, but don’t have your analytical insight and compassion. You are saying it for people who can’t say it because they don’t have the words to describe what is happening to them. You are saying it for people who don’t want to admit it to themselves. You are saying it for people who are so badly nonfunctional that they can’t lift their heads and hands to express themselves. You are saying it for people who are dead because they didn’t have enough strength, through absolutely no fault of their own, to cope with their depression. On behalf of those people, and myself, thank you for speaking out. It is necessary, absolutely necessary, that someone should say these things.

        Self-pity is unattractive, surely. So is screaming in pain if your leg is torn off in an industrial accident. I don’t think a little Max Factor and Chanel No. 5 and a Dior gown is going to make any difference to the pain. We have a right to say ouch when we hurt, goddammit, even if nobody wants to hear it.

        • Berna says:

          Hear, hear!

        • Deiseach says:

          It’s very hard to describe to people what it’s like, when they haven’t experienced it themselves. My late father used to have panic attacks, but no matter how he tried to tell us what they were like, and no matter the hours we spent calming him down and being with him, it wasn’t until I had one myself that I really understood what was going on.

          From the outside, it’s easy to say “Calm down” or “Pull yourself together” because from the outside, it doesn’t look that big a deal. For a panic attack, it’s nearly impossible to describe the sense of existential dread and terror; for depression, how it’s a constant, dragging weight, an enveloping shroud over everything, so that you can sit in a dirty house, in clothes you’ve been wearing for days, not washing yourself, not cooking, knowing what you should be doing, wanting to do it, but unable to motivate yourself, to get the energy to do it.

          And of course, to someone who’s never felt that way, it looks like laziness, like all you need is a good kick up the backside to get you moving. Because you’re not in physical pain, and you’re not having hallucinations or seizures or imagining you’re made of glass, so all you need is to pull yourself together – particularly when there is no obvious triggering scenario, when you haven’t suffered a bereavement or lost your job or been diagnosed with a serious illness.

          And sure, exercise and fresh air and getting enough sleep and not permitting yourself to be socially isolated will all help, but it’s so hard to express how you can’t do that, because what’s stopping you? It’s all in your head! (And that’s the trouble; it’s all in your head).

      • caryatis says:

        I’m sorry. But, not everyone is like you. Other depressed people react differently. And of course people who have been depressed in the past may be more able to get past it than you are now.

      • “you’re less likely to talk about it” doesn’t mean “you certainly won’t talk about it.” You talk about it for the reasons you explain. Other people might well talk about it for the reasons Caryatis implies. If so, “people who talk about it” might well be a biased sample, as I think Caryatis is suggesting.

        People who don’t have your option of talking about it in the somewhat less uncomfortable context of online discussion and don’t have the incentive of thinking other people will be interested to make them talk about it in real space might end up not talking about it at all.

    • Glen Raphael says:


      >> “And part of what I’m going on is the stated experience of depressed people themselves.”

      > So you quote one person?

      The first hyperbole-and-a-half post that Scott links to is indeed the quoted experience of one person…followed by over FOUR THOUSAND COMMENTS in which hundreds of commenters say things like [these are actual quotes]:

      “This has been me in the past, and I’m so glad I’m not alone.” “I could have sworn that you were writing about me.” “You explained the whole experience perfectly.” “So, not to sound cliche, but this was totally me. ” “Sounds familiar. Even the laundry part. Sometimes it’s totally worth it to get to the not-giving-a-fuck part, though.”

      • caryatis says:

        It was a popular blog post, I like it too, but this is not how accurately sampling a population works.

    • Scott Alexander says:

      I was intending to use it as a pointer to a very large corpus of similar testimonials.

      I’m not sure if there’s ever been a good survey of depressed people about this kind of thing.

      • Peter says:

        Statistically rigorous testimonal gathering! If you could combine the merits of rigourous sampling and the flexibility of free text, then you’d get something really valuable – at least something that would really impress me. So why don’t I see it?

    • Paul Torek says:

      I would like to point out a particular passage in what that one person wrote:

      The problem might not even have a solution. But you aren’t necessarily looking for solutions. You’re maybe just looking for someone to say “sorry about how dead your fish are” or “wow, those are super dead. I still like you, though.”

      Hmm … isn’t that interesting?

  24. moridinamael says:

    So, I get that it’s complicated.

    But, I mean, I work on things that are complicated too. We make models (which is another word for hypotheses) and test them. We keep doing this, getting new data, coming up with more refined models, sometimes changing previous assumptions. Yknow, doing science.

    So –

    > “Well, it’s complicated, but basically in people who are genetically predisposed, some sort of precipitating factor, which can be anything from a disruption in circadian rhythm to a stressful event that increases levels of cortisol to anything that activates the immune system into a pro-inflammatory mode, is going to trigger a bunch of different changes along metabolic pathways that shifts all of them into a different attractor state. This can involve the release of cytokines which cause neuroinflammation which shifts the balance between kynurinins and serotonin in the tryptophan pathway, or a decrease in secretion of brain-derived neutrotrophic factor which inhibits hippocampal neurogenesis, and for some reason all of this also seems to elevate serotonin in the raphe nuclei but decrease it in the hippocampus, and probably other monoamines like dopamine and norepinephrine are involved as well, and of course we can’t forget the hypothalamopituitaryadrenocortical axis, although for all I know this is all total bunk and the real culprit is some other system that has downstream effects on all of these or just…”

    If this paragraph describes weakly believed possibilities, can’t they be tested, separately and in conjunction? If it contains a strongly held model, why can’t they be used to more reliably solve the underlying problem? (Like, maybe this is naive, but if you had the exactly right theory of depression then you should be able to fix it almost all the time, right?) If the models are accurate but can’t be used to solve the problem, then the models must be considered to be so incomplete as to be irrelevant once the actual model is discovered.

    I mean, if your model predicts that a dropped apple will fall upward 40% of the time, then your model is awful. So awful that you’ll be embarrassed about it when you discover even Newtonian gravitation.

    If your model predicts that apples fall down 95% of the time, it’s not perfect but it should be sufficient to help most people with their apple dropping problems.

    Again, I get that it’s complicated, but I also suspect that the actual solution is not going to be 1,500 different drugs you have to take every day. Complexity is in the mind, etc., so the issue is either in hypothesis generation or hypothesis testing.

    Of course I’m an idiot, and thousands of extremely smart people are trying to nail down the solution to this problem and if they haven’t done it there’s a good reason, I’m just trying to sort through my own confusion.

    • Who wouldn't want to be Anonymous says:

      I really hate the use of gravity as an example of hypothesis testing for a whole battery of reasons.

      In this particular case, [one of] the problem[s] is that the effects of gravity at human scale are obvious. Nobody seriously goes to a physicist because they dropped an apple on their foot and want a patient explain why the apple fell down. The point whole is that biology is really, really, really complex. And unintuitive. A much better example would be trying to explain to a layman the role of gravity in neutrino/anti-neutrino annihilation. I mean, sure, there are some theories but only like six people in the world actually understand them and they have a fuckall of a time trying to even think of ways to test those theories. The best answer you can give is “its complicated and if you want a better answer you need to go spend ten years in school getting the background and then you might be ready to start learning about the theories.” People don’t like that answer so you bullshit them a little bit about “well it might involve string theory” until they shut up.

      In the biology realm you replace “string theory” with “chemical imbalance” for much the same reason.

    • Scott Alexander says:

      They’ve all been tested, and they all sort of seem to be vaguely statistically true, in that a few more studies will find small differences between the depressed and nondepressed population than will fail to find them. Now what?

  25. Ialdabaoth says:

    The problem I have with this entire line of reasoning:

    If I accept the underlying thesis that “depression is physical because all brain stuff is physical, and it doesn’t respond to social incentives” -> “depression should be treated like a disease, not like a moral weakness”, but I still want to treat depression like a moral weakness, why not cash out the other way and treat muscular dystrophy as a moral weakness?

    After all, in a reductionist universe, everything is just chemicals in your body; if my real concern is “is this someone whose net utility to me is better served by nurturing their growth, or by chopping them up and feeding them to my dogs?”, then why not just swallow the bullet and go full ‘Lebensunwertes Leben’ on anyone who can’t defend themselves against the rest of us?

    • Izaak Weiss says:

      Your first paragraph: Because treating depression and muscular dystrophy as moral weaknesses doesn’t work at curing them, so if you’re trying to get people to stop having muscular dystrophy and depression, it won’t work.

      Your second paragraph: We tried that for the majority of human history, and guess what, we didn’t like that very much.

      • vV_Vv says:

        Well, throwing the “unfit” into the chasm of Mt. Taygetos may not cure them but is a way of dealing with them. To the extent that their conditions are inheritable, it is also a form of eugenics.

      • Jaskologist says:

        Depends on your definition of “cure.” Remove the man, remove the problem.

        Note that one hardly needs the concept of moral failing to do this. Every assembly line has some Quality Assurance at the end to seek out defective product. When a defect is found, they do not blame that individual product for it. But they still toss it into the trash.

    • Scott Alexander says:

      I mean, at some point this bottoms out in pragmatism – if you treat muscular dystrophy as a moral weakness, you’re going to be sending people with muscular dystrophy to a lot of churches and brainwashing camps with absolutely nothing to show for your money.

      • Ialdabaoth says:

        Not necessarily; if you employ a literal “sink or swim” cure for muscular dystrophy at some Cuban teen “tough love” camp, for example, the kid’s not going to be around long enough to rack up a hugely expensive bill – at that point, everyone’s basically running a tacit “I take your kid outside legal juristiction and drown them for you, and you no longer have to take care of the little shit or go to jail for having him killed, because we provide the value-add service of ‘you get to call it therapy and cry and say it was a terrible shame’.”

        (I leave snapping the metaphors as an exercise for the reader)

    • Maware says:

      Samuel Butler’s Erewhon had a delicious parody/prescience of this, in which sufferers from bronchitis or pulmonary consumption were brought to trial and sentence to confinement and hard labor. Sickness as moral failing.

  26. Who wouldn't want to be Anonymous says:

    “Everything is biology, and biology is mutable.”

    The only question is which biological mechanism is most effective at achieving the desired result: repetitive input through the macro-senses like sight and sound, or repetitive input through the micro-senses like your adenosine and dopamine receptors. Take “you are at risk for X so you should work out more” as an example. It is easy to get someone to work out, but getting yelled at about it all day every day by a Drill Sergeant is pretty inefficient. If X is serious enough, a responsible doctor would also prescribe an appropriate medication to help mitigate the risk in addition to nagging sessions about working out in the off chance you happen to be one of the people that respond to nagging.

    Going back to the matter at hand, even the most determined Drill can’t get you out of bed if you are depressed enough. They might be marginally effective on intermediate cases. A good prescription can be effective at all levels, and similarly does not preclude properly constructed nagging.

    • Paul Torek says:

      How about non-repetitive input through senses like vision and hearing? Like – oh, I dunno – dialogue? It can even be modulated in a responsive way based on the sights and sounds that the depressed person generates.

  27. Faradn says:

    Among psychologists talking among themselves, I’m sure they didn’t reduce it to “not enough serotonin.” They sure do present it that way to patients, though, if my experience is any indication. Maybe the real issue is psychiatrists treating their patients like they’re stupid.

    • Hari Seldon says:

      It is difficult being on the other side of the patient / provider encounter and trying to present things in a manner your patient can understand. Things that took you years of schooling and practice to really understand don’t boil down easily to a 3-4 minute conversation.

      Even educated professionals can turn seemingly simple statements from their doctor into terrible, unrecognizable distortions. The level of ignorance (not necessarily stupidity) in the general public is astounding. Things get explained at a 4th grade level because the 50 patients before you were struggling to understand even that much. If you need a deeper level of understanding, sometimes you have to ask.

      • Izaak Weiss says:

        This is good advice; most doctors will probably be happy to share more information with you. After I took a test with my counselor to look for ADHD (which the test says I probably have), I asked if she could give me the entire results instead of just summing them up for me. She was happy to, and I understand how the test works and what my results were to my satisfaction now.

        • Depends on the doctor, and perhaps also time and place. When I was a post-doc at Columbia I had a test for blood cholesterol (at my father’s suggestion, because he had just had serious heart problems leading to bypass surgery). The doctor told me I had no problem. I asked him what the numbers were and he initially refused to tell me. My impression was that he eventually gave in when he realized I was a post-doc, hence presumably more responsible than an undergraduate (or grad student?).

          My guess was that he was working on the theory that if you tell patients too much they may decide they can make decisions for themselves rather than doing as their doctor tells them.

      • Jon H says:

        It’s kind of like communicating with a technical service person or auto mechanic, when you’re a technically proficient person yourself. Asking some questions or making some relevant small talk can help the other person work out what level of detail you can probably handle.

    • Scott Alexander says:

      Doctors are specifically told to do this because it’s like a 50-50 chance that their patients even know what a cell is, or think “chemicals” are bad things in food that cause cancer, or think that an HIV test coming back “positive” is good (a positive thing happened!).

      Once people have finally beaten into your head that you shouldn’t use complicated medical ideas with patients, it’s an uphill battle to re-learn that some of the time for some patients you can use complicated medical ideas.

      • Deiseach says:

        Just had my third annual eye exam with the ophthalmologist/consultant ophthalmic surgeon because diabetes affects your eyes and is likely to result in lovely things like diabetic retinopathy, and he kicked off this appointment with “And this visit I’m going to check your eyes for cataracts”.

        Because apparently with diabetes, cataracts are also a thing that is more likely.

        I told him “You always tell me such cheerful things every time”, but weirdly this approach works better for me than the one used by the gynaecologist who, after I reeled off my list of symptoms, said he’d like to make an appointment to do a procedure.

        “You think it’s cancer”, I said.

        “Ah, ha ha ha! No, I’m not saying it’s anything at this stage, we just need to do this to check”, he said, even though I knew by the go of him he was thinking “could be cancer”.

        I get home, hit Google, luck out on a site for medical students aspiring to specialise in gynaecology and yep – at my age and condition, with these set of symptoms, first diagnosis you think of is “cancer”.

        It wasn’t cancer, as I damn well knew, but I would much rather that my doctor had told me honestly “Yes, that’s the likeliest explanation, but we’re not saying it is the explanation until after we do this”.

        Anyway, you’ll doubtless be pleased to know my ophthalmologist says I have lovely clear lens, no sign of a cataract (yet) 🙂

  28. aguycalledjohn says:

    I also find it useful on a personal level. Rather than thinking “oh my god i feel like everyone hates me and evereything is awful why is that, is it true, am i just lazy….” ad infinitum being able to say “the reason I feel bad is because my brain is fucked up” helps a lot.

  29. simon says:

    A fine rant. Thanks Scott.

  30. MC says:

    “Julia used to say, ‘Poor Sebastian. It’s something chemical in him.’ That was the cant phrase of the time, derived from heaven knows what misconception of popular science. ‘There’s something chemical between them’ was used to explain the overmastering hate or love of any two people. It was the old concept of determinism in a new form. I do not believe there was anything chemical in my friend.”

    • Deiseach says:

      In sooth, I know not why I am so sad:
      It wearies me; you say it wearies you;
      But how I caught it, found it, or came by it,
      What stuff ’tis made of, whereof it is born,
      I am to learn;
      And such a want-wit sadness makes of me,
      That I have much ado to know myself.

    • Tracy W says:

      I do not believe there was anything chemical in my friend.”

      I always take my scientific understandings from artists specialising in architectural drawings.

      • MC says:

        The point of my quoting it is not that Charles was right, but that society has always used pat explanations with a dubious scientific basis to explain human behavior. You have to admit the breeziness with which people chalk very complicated things up to “something chemical” is both silly and entirely commonplace.

  31. ululio says:

    I don’t have depression thankfully, but I’m familiar with the experience of feeling sad for no reason at all, it may last as little as half a day. Everybody asks “what’s up, why are you so sad, what happened, come on you can trust me, you can open up to me” no look, I’m not holding any secret, it really is nothing.
    So I paid attention, and now I know some of the biological things that make me happy or unhappy. Often related to sleep and diet. It was really a huge improvement the day it sank in for me that “IT’S ALL PHYSICAL! MY PROBLEMS ARE ALL PHYSICAL!” and by physical I meant the same thing Scott call “biological” of course. Since then I try to interact with my body to make IT happier. Sleep, diet, ensuring that breathing is efficient, sleep, eating.

    • onyomi says:

      Yes, I think this is the key.

      I think sometimes proponents of the “you just need to buck up” theory are also concerned that, if told depression is biological, it will discourage patients from taking responsibility for it.

      I think it is biological, but I *also* think most people with mental health problems can and should take responsibility for their own health by observing the cause and effect of what does and does not help them. This may be drugs in some cases, but it’s also things like exercise, meditation, diet, time spent outdoors, etc. etc. There may be extreme cases where a person literally cannot muster any motivation to even make small lifestyle changes, and in such cases drugs or more serious intervention may be needed; but in most cases, I think it is possible for people to make lifestyle changes, if only small ones at first.

      In cases when lifestyle changes alone aren’t enough, drugs may also be necessary, and observing cause and effect re. which drugs help is also part of taking responsibility for one’s mental health, I’d say. Of course, there are probably people too young and/or unobservant to figure out things like “my mental health gets better when I exercise regularly,” but I don’t think that applies to anyone here.

      But the key is, the lifestyle change cannot come purely from your “attitude.” One cannot simply make up one’s mind to be more cheerful or not worry so much. One must do things which cause that change in the brain, like meditation, exercise, etc.; one cannot effectively use the brain to change the brain directly, in my experience.

      The problem is that this is counterintuitive to many people since it seems like if you have the free will to decide to move your little finger or the free will to plan some complex event in the external world, how much more should the brain have free will to tell itself what to do? Yet I find it really does not.

      If you treat your brain like just another organ, as opposed to *you*, however, things work better. You would not *will* your lungs to be healthier, for example; rather you would take up jogging and quit smoking. Similarly, you cannot will your brain to be healthier, but you can do things you know are good for it.

      • houseboatonstyx says:

        This, very much. But the trouble is, that “It’s biological” suggests to many patients that either nothing can be done (it’s genetic or some permanent defect), or nothing short of some big deal medical intervention. This is like the equivocation Scott talked about in a previous entry: by “It’s biological” he can mean it’s lead in the air etc, but most people will take it as meaning something unchangeable (because they see the central meaning of ‘biological’ as ‘genetic’ etc).

        “It’s a chemical imbalance” avoids that problem. We think of “an imbalance” as something very much fixable, probably just needing a little tweaking. But that term also takes the problem out of the moral category, or a Freudian worst of both worlds.

      • Tracy W says:

        If a person prefers taking anti-depression drugs, with all their side-effects, to making lifestyle changes, why shouldn’t they take the drugs?

        Obviously, unless the drugs are all paid for out of pocket, then taking drugs rather than lifestyle changes puts some of the costs of drugs on others, so someone’s incentives might be biased towards taking the drugs. But, making lifestyle changes puts all of the costs on the person whose lifestyle it is, so the rest of us are likely to be biased towards lifestyle changes.

  32. HeelBearCub says:

    Note the two updates on the original io9 article:

    Update: This piece originally stated that “studies have shown that much of [antidepressants’] effect is likely due to placebo.” In fact, meta analyses have concluded that the magnitude of benefit of antidepressant medication compared with placebo tends to increase with severity of depression symptoms. The piece has been revised to clarify this point.

    Update #2: As many readers have pointed out, this piece originally overstated several of its points regarding the validity of the chemical imbalance theory. While it is certainly incomplete, aspects of the theory may one day fit into a more complex and comprehensive understanding of depression. The headline and various sections throughout the piece have been revised to correct this. We apologize for the error, and thank those of you who called us out on the mistake.

    Frankly, I wonder if the author understood these two points at the beginning, whether the article would have been written at all. I feel that it certainly would not have had nearly so much of a “breathless” tone throughout.

  33. Adam says:

    This is a professor at KU who has been studying depression for a while now and better ways to treat it. Lots of great info in this video.

    https://www.youtube.com/watch?v=7HDFEbsGRlA

    And there’s a really important correlation to notice. Anti-depression use has increased dramatically over the last 30-40 years. Rate of depression has also increased dramatically over that same time frame. If the anti-depressants were working, the depression rate wouldn’t be increasing.

    • HeelBearCub says:

      “f the anti-depressants were working, the depression rate wouldn’t be increasing.”

      That doesn’t follow at all. Anti-depressants don’t prevent depression. They aren’t taken prophylactically or given like vaccines.

    • Izaak Weiss says:

      Medicine gets better -> We can tell who has what diseases more easily and treat them more easily -> More people have access to treatment for their diseases -> “The rate of disease has gone up recently” -> “Medicine must not be better”

      • Creutzer says:

        What you count is presumably diagnoses before treatment. This count tells you nothing about the efficacy of treatments.

    • Jon H says:

      It might say that, if nothing else had changed in the last 30-40 years.

  34. Eggo says:

    “I should stop using my “mirror neurons” and my social skills module to figure out where I went wrong or where he went wrong.”

    I worry about where that’s going to take us in the long run. Being able to sideline social and moral reasoning about all human behaviour in favour of “complicated science stuff that you don’t understand, but your betters do” is going to disenfranchise the general public if starts being used as a political weapon.
    And if it works as a weapon, it’ll be used as one.

    Those colleagues who talk about schools being full of, “you know, those people” are going to have a field day when they can claim those people are only that way because they have a chemical disorder they’re too stupid to understand.

  35. PGD says:

    I think people are kind of using a straw man in the way they describe ‘moral’ non-physical approaches to depression. I mean, basically heaping moralistic abuse on a depressed person is likely to be a bad idea completely independently of whether depression is best approached through interventions in the social environment or through chemical interventions. You don’t need to be much of a psychologist to see why yelling YOU SUCK GET OUT OF BED YOU LAZY ASSHOLE would be a bad idea for a depressed person. It’s like saying that the proper physical intervention is to hit them on the head with a hammer to get their brain started again. (Come to think of it shock therapy might not be far off from that).

    Why not say that giving someone meaningful work they can handle combined with emotional support from caring people who value them is the proper ‘social’ intervention with depressed people? And if the reply to that is — well, that might work but it’s very expensive and hard to do — precisely, that is an important reason why we resort to pills instead. Not because the physical approach is necessarily the scientifically proven intervention as compared to an intervention in the social environment, but because the social environment is devilishly difficult to change.

    Note that this is a different case then a ‘true’ physical disease — if you are infected with pneumonia you probably need anti-biotics above and beyond social supports. Not sure we are at that level of understanding with depression.

    • Ialdabaoth says:

      Analogous situation!

      I’ve been playing a MMO game recently with first-person shooter elements.

      I’ve been less than excellent at it.

      The game has a mechanic whereby, after dying, players get to spectate the survivors.

      This results in many, many people spectating me as I struggle with the controls.

      Most suggestions that I receive seem to revolve around surgically removing my genitals and anally raping myself with them, then uninstalling the game, then killing myself.

      (This is from my own teammates, who DIED BEFORE I DID.)

      Recently, someone actually commented that my trouble aiming looked like a framerate issue, and described in detail how to check my framerate. It turned out I was playing the game at 8 fps, which is utterly unplayable. At which point he complimented me on how well I was doing under those constraints, and walked me through trying things until I hit on a workable configuration of settings that lets me play at 40-45 FPS.

      I’m still not *great* at the game, but I can actually contribute meaninfully about half the time, and now I’m only told to kill myself at roughly the base rate.

      I went onto the game forums and pointed this out, and was effectively told in PM that killing myself would have solved the problem faster.

      People, in general, don’t WANT actual solutions to poorly-performing teammates. They want to be able to punish poorly-performing teammates – ESPECIALLY when they are worried about being seen as poorly performing themselves.

      • Elissa says:

        People, in general

        I identify as a Person In General and I am offended >:(

      • James Picone says:

        People, in general, don’t WANT actual solutions to poorly-performing teammates. They want to be able to punish poorly-performing teammates – ESPECIALLY when they are worried about being seen as poorly performing themselves.

        This seems accurate to me. DOTA players only seem to harass their teammates when they’re losing (or, at the very least, feel like they’re losing). When they’re /winning/ it tends to be more “Wow you guys are terrible” at the other team.

        It turned out I was playing the game at 8 fps, which is utterly unplayable.

        I’m kind of amazed you hadn’t noticed that.

        • Ialdabaoth says:

          I’m kind of amazed you hadn’t noticed that.

          I’m a filthy casual; I rarely find video games that I enjoy playing, so I rarely play video games. I am unused to what 30fps looks/feels like.

          • James Picone says:

            Ah, fair enough. I have a sneaking suspicion I might be atypically good at picking framerate, too – the difference between 30fps and 60fps is very visible and jarring to me, as is vsync.

            I’m kind of boggled that you could do anything at all at 8fps. The people you were playing with were probably getting something like five to ten times as much aiming information as you, and if the game is poorly programmed and only takes input on a frame-by-frame basis, five to ten times as many inputs. Any kills you got under those conditions are personal triumphs.

          • Cauê says:

            8 fps, and without realizing it, tells me you must have been playing outrageously poorly… The reaction was thus probably worse than the average experience of someone who simply plays “poorly”.

            That said,

            People, in general, don’t WANT actual solutions to poorly-performing teammates. They want to be able to punish poorly-performing teammates – ESPECIALLY when they are worried about being seen as poorly performing themselves.

            This is good. Looks like an adaptation-executer-not-fitness-maximizer thing, as in “we don’t want to have enough energy and proteins, what we want is to eat tasty foods”.

          • Ialdabaoth says:

            Note: When I was younger and into shooters, I always had the most terrible rig of our LAN party group, so I grew up playing shooters in the 10-15fps range. This might be part of why I do better than average at low fps, and why it’s harder for me to notice that anything is ‘wrong’ when playing at low fps.

    • Tracy W says:

      Why not say that giving someone meaningful work they can handle combined with emotional support from caring people who value them is the proper ‘social’ intervention with depressed people?

      Because we don’t want to land a massive guilt trip on the shoulders of the caring people who value the person with depression in the event they don’t recover? Plus an opening for emotionally-abusive people to say “If I’m depressed, it’s your fault”.

      I think we should be awfully cautious about attributing any behaviour to a lack of support from loved ones.

      • Paul Torek says:

        There are a fair number of depressed people who will tell you that they have a severe shortage of loved ones in their life. There are also a fair number of loved ones who are eager to help but lack the skills. There are also, unfortunately, a fair number who oscillate between help and conflict or abuse, or just stick to the latter.

  36. Jon H says:

    The author of the io9 piece clearly has a bit of a, shall we say, viewpoint, about pharmaceutical treatment of neurological conditions, seeing as how he used the word “PharmaCrack” to describe ritalin and adderall.

    • Scott Alexander says:

      Adderall is kind of PharmaCrack.

      • Elissa says:

        Adderall is precisely PharmaSpeed*; calling it PharmaCrack feels like both a missed opportunity and an unfair implication that this is a big secret. Generic Adderall comes in a bottle that says “mixed amphetamine salts”.

        *You can take my word on this based on my recent track record of choosing the correct arrow on a synapse diagram over 80% of the time

  37. Evan Isaac says:

    Your characterization of the two statements as (A) is overly generous, bordering on intellectual dishonesty, IMO.

    There is nothing in either quote that comes close to the level of doubt (understanding that no conclusion in biology is final) as is expressed in your (A).

    This isn’t specific to psychiatry, however, and is a plague of almost all biological sciences (at least medical and psychiatry): math envy. logic envy, whatever you want to call it.

    They don’t seem to understand that they just don’t get to make statements of fact the same way that mathematicians and philosophers can. But they just do it anyway.

    • Jesse Forgione says:

      I agree with you that (A) is too generous, not just because it expresses too much doubt, but because it actually misrepresents the position in a qualitative way too. They obviously DID want to say that depression is caused by chemistry, as opposed to the other way around.

      (B) is also a mischaracterization, because the accusation is not that they thought they understood depression “perfectly,” but that they thought it was essentially caused by a chemical imbalance, which is exactly what they thought.

  38. Paul Torek says:

    I’ve been highly critical of Scott in the comments, but I want to sing his praises for one thing:

    “We don’t know exactly, but it probably involves problems with brain structure and brain chemicals,” maybe.

    Since brain structure includes FINE brain structure, like synapses and their weights in causing the neuron to fire, this is a GINORMOUS leap ahead of “chemical imbalance.”

    It includes the neural network responsible for memories, for emotions that are about specific things, for skills, for beliefs, and so on. Like the neurotransmitters (only more so), that neural network is very powerful. Unlike the neurotransmitters, it is very subtle – you don’t need to whack the brain with a big chemical stick and hope that the net direction of movement is life-enhancing. There are many dimensions, to put it mildly, along which the neural network can change.

    When the human brain grew to matricidal proportions (and the human race flourished despite that), we were learning how to use language. This is probably not a coincidence, and probably involves at least some causation in the language -> brain size direction (needless to say, there is no exclusion of feedback loops here). I’m saying: speech, man! It’s how you access the neural network.

    Go and be powerful, young man.

  39. Alia D. says:

    But what if it’s both something that calls for more than just attributing everything to “free will” but also calls for looking at thoughts and behaviors rather than just focussing exclusively on the chemical imbalance.

    Like suppose depression is an old system for what to do in the face on an oncoming winter with not enough food and other resources. It makes sense to trigger survival behaviors by taking the “fun” out of activities so less energy would be wasted, making you feel tired so you spend as much time as possible curled up in a ball sleeping to conserve energy, tagging every anxiety provoking thought for recurrence so you remember to keep an eye on resources that might get critically low, shifting food preferences to the type of fall food that spoils most easily so that it can be stored as fat, et cetera. While there might be various triggers that could indicate a coming starvation winter, a very important one would be a higher cognition based awareness that not enough food had been stored, based on a rational analysis of the situation. Now an autonomous system might not be able to capture all the fine detail of the rational analysis and just have a trigger tied to DireThoughts detected in the portions of the brain supporting consciousness. So conscious thoughts and behaviour can become part of of a vicious cycle. A person thinks “Nothing is fun anymore. I’m not even sure what my purpose in living is. This is awful” > the automatic systems tag this as more DireThoughts detected. > we must not be conserving enough energy yet. > more depression coming up via neurochemicals. Condition detected: hardly any physical movement today > there must not be any more food available to gather, but DireThoughts are still present > more depression coming up.

    Whether the vicious cycle was originally started by an overactive chemical system or by too many DireThoughs, it might make sense to treat both parts of the mis-functioning system. A simple “chemical imbalance” or other “it’s biology stuff” explanation is good for relieving thoughts that “it should be easy to get over this with just a little effort” that are probably making the person more depressed. But it our society it’s common to oversimplify cartesian dualism and take it too far. Many people think “biology stuff” means it’s totally disconnected from their thoughts and decisions, except the decision to take the right pill for it.

    I do think that an explanation that is strictly biological will lead those who don’t think of thoughts as biological, which is most people, to neglect common sense tries that might help break the cycles, like avoiding news articles on far away tragedies when their read doesn’t produce any good and only makes them anxious, even, or perhaps especially, when the articles start to invoke an almost hypnotic fascination.

  40. RCF says:

    A blackout is a state of superinhibition? My understanding is that is only the log-term memory formation that’s being inhibited. The rest of the brain is working just fine (other than being drunk).

  41. RCF says:

    Blackouts are instances of being super inhibited? My understanding is that in a blackout, it’s just the long-term memory formation that’s inhibited. Other than being drunk, the rest of the brain is working just fine.

  42. Pingback: Morning Break: Diet Pill Fail, Facebook and Depression | The Today Online

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  44. Michael L Pipkin, MD says:

    An excellent post. I have practiced psychiatry since the early days of medication treatment for mood disorders, and although I don’t think I have ever called anything a “chemical imbalance”, every day I have to present to frightened, suffering people the model that I think represents the best approach to understanding their difficulties. And often, when I explain that they appear to be suffering from a biological disorder that should be treated with medication, the response is “You mean it’s a chemical imbalance?” Because that is what they have heard about.

    So I tell them, yes, that’s an oversimplification, but yes, this is a medical problem, not a personal failing, and there are medicines that probably will help. And about as often, people think there must be a pill that will substitute for solving a difficult problem, or can take away unhappiness. Getting the diagnosis right really matters, not just the over-broad DSM category, but a real understanding of constitutional, developmental, psychodynamic, and social contributions to a patient’s experience.

    Who really buys into unscientific nonsense about chemicals? Try the hucksters in the supplements industry and the non-physician practitioners who claim to measure metabolites in urine and “prescribe” nutritional potions.

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  46. a friend says:

    There is something very basic that you are misunderstanding, Scott. The reality is, they often said both (A) and (B) in the same breath. Now you’re analyzing that scientifically and saying, no, those are scientifically incompatible statements, they could not have said both simultaneously, no one would have let them. Yet they did. That’s because this whole thing did not play out in the scientific literature. As both you and the antipsychiatrists agree, in the scientific literature, no one ever produced strong evidence to support the serotonin hypothesis. Instead, this whole thing played out in the world of public relations and marketing.

    So now analyze this issue from a PR perspective. Think of it like when a nuclear accident happens, and a nuclear expert goes on TV and says to everyone, “No one can ever know anything for 100% certainty, and we’re still gathering data every day and learning about the complexities of what’s happening out there. Nevertheless, the balance of evidence and expert opinion so far suggest that there’s no danger to the general public.” That statement is scientifically fairly open-ended with lots of wiggle room, but from a PR perspective it’s clearly designed to reassure and inspire confidence in the public, and that’s exactly what it does for most people most of the time. And all you have to do is go into a library media database and you’ll find thousands upon thousands of articles for decades where psychiatrists said both (A) and (B) at the same time in ways that reassured and inspired confidence in people that the science was saying that boosting serotonin had a very good chance of alleviating depression.

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  49. Altostrata says:

    From a patient point of view, “The idea that depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry” is laughable.

    Millions of patients have been told, in all seriousness, by psychiatrists that their “depression” (so very flexibly diagnosed) is due to a “serotonin deficiency” or “chemical imbalance” and that psychiatric drugs correct this. (“Like insulin for diabetes.”) This dishonest compliance-engendering strategy is being used to this very day.

    Either the doctors were disingenuous or they drank the Kool-Aid. Neither characterization is palatable for the profession of psychiatry, so to preserve self-regard, some representatives take the third way out: Blanket denial.

    The truth is that some psychiatrists were always wary of the monoamine hypothesis, but most shrugged, went with the flow, and parroted that oh-so-easy party line. Rewriting of history does nothing to restore trust in the profession.