Things That Sometimes Help If You Have Depression

Some of my friends have depression and have asked me for some suggestions.

These will be inferior to reading official suggestions, but you will probably not read official suggestions, and you may read this. Just so we’re clear, all opinions here are my own, they are not endorsed by the hospital I work at, they do not constitute medical advice, I have a known habit of being too intrigued by extremely weird experimental ideas for my own good, and you read this at your own risk. I am still an intern (a very new doctor) and my knowledge is still very slim compared to more experienced professionals.

Overall I think this is more of a starting point for your own research rather than something I would expect people to have good results following exactly as written.

And one more apology: originally I tried to include links to appropriate studies with each intervention, but there are so many different studies, and it’s so easy to pick apart each, and so much of the research is based on a gestalt impression after having read three dozen studies rather than on any individual one – that I decided that listing the evidence fairly would require this to be ten times as long and much more academic. I’m doing that thing where “perfect is the enemy of good enough” and trying to actually get this up online. I’m happy to discuss evidence or lack thereof for any particular therapy in the comments.

Now that that’s over: first I’m going to talk about figuring out if you need help. Then I’m going to recommend you see a psychiatrist. Then I’m going to accept that in reality a lot of people for whatever reason can’t or won’t see a psychiatrist, and grudgingly recommend some lifestyle interventions you can make. Then I’m going to accept that in reality a lot of people for whatever reason can’t or won’t make lifestyle interventions, and grudgingly recommend some over-the-counter medications and supplements that might be helpful.

I. Do You Have Depression?

Major depressive disorder is the clinical condition that best corresponds to what people usually mean when they say “depression”. Only a licensed professional can officially determine whether or not you have major depressive disorder. But if you feel miserable all the time, you might be able to make one heck of a good guess.

The PHQ-9 is a well-known and validated screening tool for depression; you can take it at the linked site. It cannot diagnose you officially, but once again, it can help you make one heck of a good guess, and if you get a high score it might inspire you to get to a doctor’s office.

Overall there’s not exactly an epidemic of perfectly healthy people misdiagnosing themselves as depressed, but there are a couple of things worth keeping in mind:

– You can have depression even if there is a good reason for you to be depressed – for example, if you’re depressed because you lost your job. If you have the symptoms, and it’s been going on more than two weeks, it counts. These kinds of depression seem to respond to treatment about the same as kinds that come on for no reason at all.

– Depression usually lasts a long time. Depressive episodes usually last weeks to months. Someone who is depressed for a day or two after something happens probably does not have depression. Even if they are unreasonably depressed for a day or two after something happens, so much so that they seem to have a mental disorder, it may be a different mental disorder.

– People with bipolar disorder (“manic-depressive disorder”) are often depressed some of the time. These depressive episodes can last a long time, just like the ones in traditional depression. However, bipolar disorder is a completely different disease and needs completely different treatment. If you sometimes have “manic” or “hypomanic” episodes – several days to weeks of having abnormally high energy, abnormally low sleep, abnormally high self-esteem, abnormally short temper, and poor impulse control – then you probably have bipolar disorder instead of depression. If your doctor or psychiatrist has diagnosed you with depression and started treating you with antidepressants and you don’t seem to be getting better, then you have found your problem. Politely bring up your history of manic or hypomanic episodes and ask whether she wouldn’t prefer to diagnose you with bipolar disorder instead.

II. Please Go To A Doctor

If you have depression, your best bet is to go to a doctor. A doctor can diagnose you and connect you with useful prescription-only medications like antidepressants. You do not need to go to a psychiatrist to get antidepressants. Your family doctor will be able to prescribe them. You will only need to go to a psychiatrist if your depression fails treatment with normal medications and someone needs to figure out a more complicated plan.

The failure mode of medical professionals I see most often seems to be something like this:

Patient: I’m depressed.
Doctor: Here, have an SSRI
Patient: (three months later) I’m still depressed.
Doctor: Well, keep taking that SSRI I gave you, I’m sure you’ll get better eventually.
Patient: (six months later) I’m still depressed.
Doctor: Sheesh! I already gave you an SSRI, what else do you want from me?

There are dozens of different depression medications. If one doesn’t work, very commonly another one will. Depression treatment is difficult, because there’s no way of knowing beforehand what medications will or won’t work for any individual person. The correct solution is to start with the safest medications, see if they work or not, and gradually move up to stronger medications with more side effects. But this doesn’t work if your doctor just tells you to keep taking whatever you’re taking forever whether or not it’s doing anything.

A lot of people are reluctant to second-guess their doctor on this sort of thing. So let me provide you with a loose approximate algorithm that you can follow when going to a doctor or psychiatrist about depression. Many doctors have very good reasons for deviating from this algorithm, but if they are nice people they should be willing to explain what their reasons are to your satisfaction.

1. Rule out organic causes

When your doctor diagnoses you with depression, they may perform several blood tests. The most important ones are a thyroid test for hypothyroidism, and a blood count for anaemia. Hypothyroidism and anaemia are medical illnesses that can cause depression. If you have them, then psychiatric treatment for depression won’t help and won’t treat the underlying potentially dangerous condition.

Symptoms of hypothyroidism besides depression include feeling unusually cold, gaining weight despite good diet, constipation, pale dry skin, weakness, and disturbed menstrual periods if female. It is easily detectable with blood tests and easily treatable with thyroid hormone, but someone’s got to look for it.

Symptoms of anaemia besides depression include looking very pale, feeling weak and tired, and occasionally pica, the compulsion to eat non-food items like ice or dirt. It is very common in women with heavy periods. It is easily detectable with blood tests and usually easily treatable with iron supplements.

If you’re being treated for depression with psychiatric medication, and it’s not helping, and you have some of those symptoms, and nobody ever did blood tests on you, politely ask your doctor if you’ve been tested for hypothyroidism and anaemia (people get lots of blood draws all the time and lots of the time they’ve just forgotten). If you haven’t been, politely ask why not. If your doctor doesn’t have a good reason, and your depression isn’t getting better, politely ask if they think it would be a good idea to check for at least those two conditions and maybe some vitamin deficiencies.

2. Choose between pharmacotherapy, psychotherapy, or both

Many to most doctors and psychiatrists will assume that you want medication. This is a pretty good assumption most of the time. Medications and psychotherapy are about equally effective in treating depression, but psychotherapy costs a lot more, takes more time, and is harder to get your insurance to cover.

Still, a lot of people who would have preferred psychotherapy never get the option. And if you’ve tried lots of medications that haven’t worked, maybe you’ll luck out with psychotherapy. You can either get your doctor to recommend someone or find someone yourself.

Cognitive-behavioral therapy is a nice neutral therapy for depression with as high a success rate as any other. It usually consists of a couple of sessions in which somebody talks to you about the way you deal with and think about problems and maybe assigns you some homework. There’s no talking about your mother or about your sexual fetishes. 6 to 12 one hour sessions would be a pretty standard starter course.

Having both psychotherapy and medication has been associated with a better treatment rate than either one alone.

3. Start with an SSRI

SSRIs are the most commonly used antidepressant medication. They are no stronger or weaker than other antidepressants, but they do have fewer side effects, which makes them first-line.

There is a lot of worry that SSRIs are not much better than a placebo for people with mild to moderate depression (almost everyone agrees they are effective for severe depression). Some studies have seemed to confirm these fears, others have seemed to refute them. I am leaning towards “marginally better than placebo”. However, this is a completely academic debate for you, because you are not going to get placebo. Your choice is between SSRIs or nothing. Everyone everywhere agrees SSRIs are much better than nothing.

All SSRIs are approximately equally effective. Your doctor or psychiatrist’s choice of SSRI comes down to which side effects you are most willing to tolerate, the exact shape of your depressive symptoms, and which drug company gives out the most pens and coffee mugs with the name of their medication on them. Celexa or Lexapro (citalopram or escitalopram) are good first choices for most people, but it is hard to go disastrously wrong here.

Bupropion is not an SSRI, but is also an appropriate first choice. SNRIs like Effexor (venlafaxine), as well as mirtazapine which is sort of in a weird little class of its own, are also okay for certain people. If your depression is very severe, your doctor might skip this step and go further down in the algorithm, which is also okay. Some psychiatrists also may have their own idiosyncratic preferences which are probably okay as well if they can explain their reasoning to you.

Many people worry about the side effects of SSRIs. In my opinion many of these worries are exaggerated. The most common side effect is decreased sexual drive and performance, which can occur in more than half of users. Other side effects include nausea, diarrhea, insomnia, and weight gain, which occur less frequently. These side effects are usually temporary and go away when you stop using the drug. If you’re worried about sexual side effects, bupropion is much less likely to have these, with the tradeoff being a few other effects like more insomnia.

Some antidepressants have discontinuation syndromes, which mean you feel sick when you’re withdrawing from them. Effexor (venlafaxine) and Paxil (paroxetine) are particularly bad. A competent doctor or psychiatrist will take you off these slowly so that you avoid any bad effects.

4. Give it a little while to work

Antidepressants take some time to start working.

This is less true now than it was a while ago – it used to be believed they almost never worked until a few weeks had gone by, whereas now we know that there can sometimes be some improvement pretty quickly. But other times there isn’t. Although you can hope for improvement within a week or two, give an antidepressant at least four weeks, just to be sure you’re not selling it short.

If you can’t wait four weeks, you may want to consider mirtazapine, which works a little more quickly. But you’re still not going to pop a single pill and start feeling much better.

5. Fiddle around

If a drug seems to work a little bit in the first month or two, it might be worth raising the dose.

If it doesn’t work at all within the first month or two, you could still try raising the dose, but you might also want to try switching to a different drug. For example, if one SSRI doesn’t work, you could try switching to a different SSRI.

If SSRIs don’t work, this might be a good time to try antidepressants from other newer classes. Effexor (venlafaxine), mirtazapine, and bupropion would be three very good choices here. All three are pretty safe and very commonly used. You could also move to a tricyclic antidepressant, which have just a little bit more side effects than some of the newer classes that have replaced them by which can sometimes be very successful in certain patients when SSRIs have failed.

If nothing works alone, your doctor will probably try combining a couple of these drugs and seeing if that helps.

6. Get serious

Once treatment with SSRIs and the usual SSRI replacements has failed, you get to start trying more serious stuff. Usually the drugs here either have worse side effects or are still a little bit experimental. These will probably be prescribed by a psychiatrist and not your regular family doctor.

Atypical antipsychotics have been found to be quite effective in depression. Unfortunately, many have side effects, including weight gain and increased risk of diabetes. Abilify has fewer of these, which makes it a very popular choice. Seroquel has a few more, but it also relieves anxiety and helps sleep, which makes it very popular as well. Olanzapine has a lot of good evidence behind its antidepressant properties, but its side effects can be very severe, so I would be more reluctant to prescribe it than either of the other two.

MAOIs are an old antidepressant medication that went out of fashion when SSRIs came around. A lot of patients remember them very fondly; according to anecdote they are very powerful and can give people a very good mood. However, they have a bad habit of causing life-threatening hypertensive crises at inconvenient times if you eat the wrong thing, where “the wrong thing” includes everything on a long list of foods your doctor has to give you and lecture you about before they can be prescribed. And just to warn you, cheese, beer, and chocolate are definitely included. The Europeans seem to have a less dangerous MAOI called mobeclomide which hasn’t been approved in the US yet, but I don’t know anything about it.

Thyroid hormone is very rarely used as an antidepressant augmentation, but there is some preliminary evidence that it is as effective as lithium with fewer side effects, even for people without obvious underlying thyroid problems.

Lithium is a mood stabilizer more commonly used in bipolar disorder, but which has some indication for depression as well. Usually it is taken along with another antidepressant as “augmentation”. It works pretty well, and is especially good at decreasing suicidality, impulsivity, and aggression. Unfortunately it’s not the safest medication in the world and usually requires some annoying blood tests to make sure you keep getting the right amount of it.

Modafinil shows some promise as an antidepressant supplementation strategy and is discussed in more detail in section IV below.

This might also be a good time to double-check that you were definitely tested for underlying medical conditions like hypothyroidism and anaemia, and that you definitely don’t have bipolar disorder or some other condition mimicking depression. Or you might want to look down and try some of the lifestyle interventions and supplements later in this list.

7. Get very, very serious

Electroconvulsive therapy gets a bad rap from old movies where we see people who “misbehave” in the mental institution getting what look like very painful electric shocks.

Modern electroconvulsive therapy is done with the patient sedated. You are pleasantly asleep, your limbs aren’t flailing about or anything, and it can be done on an outpatient basis with you going home as soon as you’re done.

There are a lot of worries about side effects. Some people experience some memory loss, especially of the couple of weeks before the treatment. Most of the time these memories come back. Sometimes they don’t. But how much do you want to remember the week when you were so depressed you needed ECT, anyway? Longer-term side effects are less well-known. Some people think a lot of ECT isn’t good for your brain, but if the effect exists it’s small enough that people are still debating whether or not they’ve really picked it up.

But the thing is, ECT really, really works. People get to the point where everything else has failed, and they’ve been on seven hundred different medications without feeling any better, and they’re ready to give up, and then they get ECT and start whistling happy songs and dancing the polka. I won’t say it works 100% of the time, because no medical treatment works 100% of the time. But in psychiatry, where expectations are always low, it’s the closest thing we’ve got to a miracle cure.

Speaking of miracle cures, a couple of people have asked me about ketamine. Ketamine does show unusually rapid and effective action in treating depression. However, it is currently still very experimental and your doctor or psychiatrist will not be able to give it to you unless by a strange coincidence they are one of the few researchers working with this drug. Further, there are still a lot of problems with ketamine therapy for depression. First, the drug is highly hallucinogenic, sometimes in very scary ways; in experiments subjects are put under anaesthetic first so they don’t have to consciously experience the hallucinations. Second, it’s not yet clear how long-acting it is; anything that required long-term ketamine therapy (say, a ketamine dose a week) would be impractical both because of the hallucinations and because the drug has serious side effects and is addictive. Although it is very exciting to researchers, it is probably not very useful to you.

Anyway, that’s the algorithm – which I lifted from a couple of treatment guidelines – that I would recommend people watch to see if their doctor follows. Because I feel like – if someone is really really depressed, to the point where it’s ruining their lives, and they are begging for help, and their psychiatrist tries all of steps one to seven, and even the ECT doesn’t help them, then they can consider saying “Well, I’ve done everything I can”, giving up, and lowering their expectations. Any doctor who gives up before they’ve reached that point has no excuse.

How do you find a good psychiatrist?

I have no great advice here, except that if you think your psychiatrist is terrible, you are probably right. Even if you are not right, your psychiatrist is apparently terrible for you. See if your insurance allows you to switch psychiatrists. If they do, try it and see if the next one is any better.

If a psychiatrist is doing something completely unlike the treatment algorithm in Part A, ask them to explain why. Be willing to accept any explanation, because treating depression is hard and there are a lot of different valid approaches. But if they refuse to explain and tell you that you’re a bad person for asking, you miiiiiiight want to see if you have other options.

There are a lot of doctor rating sites. or are among the bigger ones. These sites are not very valuable on the margin; you do sometimes get one guy who had to sit in the waiting room a little too long going on a personal campaign to destroy someone’s reputation. But on the tails, if there’s a doctor who is universally hated by every single one of her patients, this can be a strong warning sign.

People in mental health support groups are absurdly willing to share their opinions of various psychiatrists. Just don’t be surprised if you can’t get them to shut up once you’ve gotten your information.

Kate Donovan has a good guide to finding a psychotherapist, with partial crossover to the skill of finding a psychiatrist.

How do you see a psychiatrist without worrying you will be committed to an institution?

This is something I see a lot of people worry about, and something that prevents a lot of people from seeing a doctor or especially a psychiatrist. I think it happens less in reality than it does in people’s fears, but it does sometimes happen in reality, and enough people avoid getting help for this reason that it’s worth discussing briefly, at the possible risk of giving more airtime to something most people should not be worrying about.

The first and most important point is that very very few psychiatrists, whether good or bad, will commit people to a mental institution unless they are very sick. Even if you are very sick, there is only a small chance of a psychiatrist committing you against your will unless you say exactly the wrong thing.

Doctors and psychiatrists are legally required to commit patients to mental institutions if those patients are “a threat to themselves or others”. Usually this means a patient has said they want to commit suicide and they are probably really going to go through with it soon, or a patient has said they’re going to hurt someone else (or implied it: “He’s gonna get what’s coming to him”) and it wasn’t clearly meant metaphorically. They may also commit you if you are very paranoid on the grounds that paranoid people may try to pre-emptively attack those they believe are plotting against them – or if you are refusing to eat, on the grounds that if you don’t eat you die.

A good psychiatrist will differentiate between vague suicidal ideation (“Sometimes I feel like life isn’t even worth living, do you know what I mean?”) and specific suicidal ideation (“I will kill myself tomorrow using the gun hidden in the back of my pantry”), will explore the first type with an aim toward helping you, and will only involuntarily commit for the second type. I do not guarantee you will have a good psychiatrist.

Until you are sure your psychiatrist is trustworthy, you may want to steer clear of statements that sound suicidal, homicidal, or paranoid. Even in jest. Especially in jest. Until you have established absolute trust, please treat joking about suicide or homicide around your psychiatrist the same way you would treat joking about terrorism around airport security agents. I cannot overemphasize how important this is. If you won’t do it for yourself, do it for the sake of your poor overworked local inpatient psychiatrist, who is sick of hearing all his new patients say “I shouldn’t be here, I promise I was only joking!”

If you are genuinely suicidal, homicidal, or paranoid, but you are absolutely sure you are not an acute danger to anybody, and you trust your psychiatrist enough to tell him or her about these things – then make sure you phrase it in a way that specifies you are not an acute danger to anybody. For example “Sometimes I feel like I would be better off dead…BUT I AM DEFINITELY NOT GOING TO COMMIT SUICIDE BECAUSE THAT IS MORALLY WRONG AND I CARE A LOT ABOUT MY FAMILY AND I WANT TO LIVE!!!”. Or “Sometimes I feel like people are plotting against me…BUT NOT ANYBODY SPECIFIC AND I KNOW THAT’S NOT ACTUALLY TRUE!!!”

This should keep you relatively safe from involuntary committment unless your psychiatrist is truly awful.

III. Lifestyle Interventions

Not everyone can or will go to a doctor, and even those who do go to a doctor might want to try something more proactive on the side, so in this section I’m going to list some lifestyle interventions you can make.

1. Do therapy on yourself

If you can’t or won’t go to a therapist, a therapy workbook is a practical alternative. Cognitive Behavioral Workbook for Depression is rated 4.3/5 stars on Amazon, which I guess is sort of like being evidence-based. Many very smart people find these sorts of therapy workbooks to be a little condescending (“Really? I need to stop catastrophizing all the time? I never would have thought of that on my own!”) but other equally smart people find them useful, whether because they have new insights or because they repackage, remind, and rehearse what they already know. For 3$ for a used copy, that’s about 1% of the cost of most of the other interventions you could try.


Put in all capitals with an exclamation point at the end of it to show how important I think it is.

Depression is weirdly linked to circadian rhythm and sleep. Poor sleep habits probably help cause and exacerbate depression. Unfortunately, depression also causes and helps exacerbate poor sleep habits, so it’s a kind of vicious cycle.

In a recent study, people who received cognitive behavioral therapy for sleep disturbances had double the recovery rate from depression of people who didn’t, suggesting that attacking insomnia is pretty much just as effective as the strongest drugs known. This avenue is severely underexplored and very promising.

The cognitive behavioral therapy for sleep disturbance is about one part basic CBT techniques of challenging your perceptions and beliefs, and one part the things your mother told you about sleeping in a dark room and not watching exciting TV shows right before bedtime. This therapy also has a cheap workbook with a 4.6 star Amazon rating. You can add whatever other high-tech exciting sleep cycle correctives you know – melatonin, magnesium, whatever – to what it tells you.

3. Exercise

I work in a psychiatric hospital. Once a week or so a social worker leads an exercise group there, and it is amazing how much better everyone does that day compared to the days before and after. Exercise seems to increase release of BDNF, an important brain chemical that depressed people don’t have enough of, and there have been several studies showing good effect.

Fast walking for a half hour five days a week seems to be enough to help. More exercise might help more. And exercising outside will get you more sunlight and vitamin D, whose relationship to depression remains controversial but which certainly can’t hurt.

4. Light therapy

Light therapy is hanging out around really bright lights for a while and hoping they cheer you up. The Cochrane Collaboration and a meta-analysis in a major psychiatric journal agree that they do, quite robustly (although there is still uncertainty about whether they add extra treatment to somebody already being treated with antidepressants).

Experts recommend a light therapy box emit 10,000 lux (a unit of light). Here’s a very official looking one that costs $200 and a somewhat less expensive one at $70. But don’t take these as recommendations – I’m just repeating out what shows up on Amazon search.

Best practice is to keep it above your line of vision so your brain feels like it’s the sun, and sit near it for at least a half hour in the morning. Mayo Clinic tells you a little more about how to do it here.

5. Drugs are bad for you, mmkay?

The Simpsons described alcohol’s role in treatment far better than I can: “There’s nothing like a depressant to cure depression.” Except I think they were being sarcastic, and a lot of patients are serious.

Alcohol probably works in helping you forget about depression for a little while, but over the long term it makes you much more depressed. If you abuse alcohol, stop doing that.

Benzodiazepines (Xanax, Ativan, Klonopin) are, once again, good short-term solutions to anxiety. If you abuse them, they will probably contribute to your depression.

Smokers have more than twice the rate of depression than nonsmokers. There’s a lot of debate about whether it’s causal or noncausal, but some sophisticated statistical modeling seems to suggest there is indeed a real link. Also, getting lung cancer is depressing as heck.

I don’t know any studies linking heroin or cocaine to depression directly, but they probably take your life in a pretty depressing direction.

Obviously all of these drugs are hard to quit, and you might need the help of a medical practitioner.

6. Other things that make you happy

Cure Together is a really neat website where people with illnesses record all the things – medical and nonmedical – they tried and how well it worked for them. It obviously trades off the well-controlled conditions of an experiment in exchange for sheer amount of data, but it’s a useful adjunct to other ways of getting information. You can find their chart for depression here.

Just from looking at it, exercise and SLEEP! are right up at the top, but people also mention things that more scientifically-inclined people would probably never think of, like spending time with a pet, listening to music, and watching funny TV shows.

IV. Supplements

Despite the best of intentions, I think a lot of people are going to skip parts II and III and start down here. I think that would be a mistake, but I understand depressed people don’t always have the energy for big lifestyle changes or the willpower to take the anxiety-provoking step of seeing a psychiatrist. So sure. Let’s try supplements.

A reminder – supplements are chemically active compounds. They can have side effects. You should look up what they are. In particular, some of them can disrupt the metabolism of other medications. Contraception is another medication. If its metabolism was disrupted without your realizing it, that could be very bad. Be careful. If you’re taking other medications, tell your doctor about any supplements you’re taking. Don’t take supplements without a doctor’s okay if you have liver damage, kidney damage, or any chronic medical condition.

And with that stirring recommendation, here are some supplements that seem promising for depression, in approximate order of recommendedness.

1. S-Adenosyl methionine (SAM-e)

This would be my first choice if you’re trying to treat depression with supplements. It has a good evidence base, big effect size, it’s pretty safe, and it’s available on Amazon for $20 a jar. It probably works both on its own and as an adjunct to antidepressants, although there’s only partial evidence for the first claim. One experiment got good results with 800 mg two times a day for six weeks, though aside from that proper dosage is anyone’s guess.

2. Creatine

Yes, the same stuff bodybuilders use. One RCT found good results at 5g per day. May be more effective in people likely to be protein-deficient (eg vegetarians) and possibly in women.

3. Folate or l-methylfolate

Folate is a form of Vitamin B9 that most people get in food. Several RCTs have found positive effects from supplementing antidepressants with folate, although the evidence for folate on its own is still lacking. Some people with a mutant version of a gene called MTHFR are unable to process folate very well, and may get better results from an “optimized” version called l-methylfolate. A psychiatric medication commonly prescribed for treatment-resistant depression, Deplin, is l-methylfolate, but the supplement version is exactly the same. 5 – 15 mg / day seems to be a common dose, even though a lot of the supplements seem to contain a lot less.

4. Saffron

Yes, the spice. I’d never even heard about this until I checked, but it seems to check out. Five different randomized controlled trials found saffron to be more effective than placebo and as effective as conventional antidepressants. Amazon seems to be flooded with sellers ever since Dr. Oz apparently said it might be a weight loss supplement. [some problems, especially for pregnant women]

5. Fish oil

A lot of people are very excited about this, including I’m more skeptical. There have been a lot of studies that suggest fish oil can improve mood in depression, and a lot of others that find no effect. And fish oil is a complicated supplement to deal with – most of the commonly sold pills don’t have enough to do any good, and if you don’t store it right it goes rancid and is worse than nothing.

Instead, I would eat a lot of fish. The degree to which the level of depression in a country correlates with the amount of fish eaten in that country is staggering. Two salmon dishes a week ought to be a good start.

6. -afinil

Modafinil is a wonder drug that gets used for everything, both legally (with prescription) and illegally (without). It was only a matter of time before someone tried it for depression, and it seems to work pretty well, at least as an adjunct to antidepressants. There are fewer studies about whether it works on its own. I would guess that it does, because the most likely mechanism is its well known tendency to increases energy and alertness, which is pretty useful against depression’s fatigue and tiredness. The strongest argument against modafinil is that it lacks a plausible mechanism for antidepressant action and so realistically you’re probably just treating symptoms. The strongest argument for is that you’re probably treating symptoms very well. Also worth noting that modafinil disturbs sleep and disturbing sleep is very bad in depression, so take it at the beginning of the day and if you still can’t sleep at night, cut the dose.

Modafinil is illegal without a prescription, but everyone on the Internet sells it anyway. Adrafinil is a prodrug that turns into modafinil once in the body. It is perfectly legal without a prescription, because the medical licensing regime makes no sense. You might as well just get that – as far as I can tell the risk of liver damage is overhyped if your liver is otherwise healthy.

7. Other things

Things I find interesting but which have conflicting evidence and/or don’t deserve a whole paragraph of their own include: lithium orotate microdosing, rhodiola, vitamin D, zinc, and curcumin. Look them up and see what you think.

Not exactly a supplement, but I’m pretty sure you can get Botox without a prescription, and if done correctly it might help substantially.

What if you want to buy antidepressants illegally without prescription?

Well, you probably won’t get caught. And you probably won’t kill yourself if you go into it semi-well-informed. I can’t in good conscience recommend it, but I’m sure it’s something a lot of people think about. Consider yourself scowled at, and at least take the following advice:

Definitely definitely do not take any tricyclics (hint: if it ends in -pramine, it’s a tricyclic) without a prescription. Those are seriously potentially dangerous. Taking MAOIs (phenelzine, tranylcypromine) without a prescription is the worst idea and you will die (note: some over the counter supplements claim to work through “MAOI-like action” or “being reversible MAOIs”. As far as I can tell these are safe, though I can’t vouch for their efficacy. Just don’t take the real thing.) I don’t even think anyone sells antipsychotics without prescription, but also the worst idea. If you are thinking of buying any of these without prescription, and you won’t accept advice to not buy prescription medications at all, can I at least talk you down into buying an ordinary relatively harmless SSRI?

For weird political reasons, tianeptine, a well-regarded foreign antidepressant, is not a prescription drug in the United States. I think it is still illegal, but everyone sells it all over the Internet, even respectable sites that wouldn’t dare sell the normal prescription antidepressants. It has a large Internet fan club that swears by it, and its side effects are less than those of many other antidepressant classes. It is available from nootropicsdepot, a supplier I regard pretty highly. If you can’t just buy normal supplements from a health food store like a normal person, it is very likely your best bet.

V. Other things

The average length of an untreated depressive episode is six months. People who have one depressive episode have an 80% chance of having another sometime in their life. The average person with major depressive disorder gets four depressive episodes during their lifetime. Take these statistics into account when deciding how proactive you want to be with treatment.

People with depression have about a 2% chance of going on to commit suicide, though obviously this varies a lot with the intensity of depression. Most people who attempt suicide later regret it and go on to live enjoyable lives. If you are feeling suicidal, there are suicide hotlines operating both by phone and by online chat. You can also go to any emergency room and ask for help. If you have health insurance, this will probably be covered. Warning: this will quite possibly result in committment to a psychiatric hospital.

If you are feeling very suicidal and don’t trust yourself not to attempt something, going to a psychiatric hospital is probably your best bet. The average length of stay at an average hospital is three to seven days. Two weeks is rare. A month is totally unheard of. You usually get intense attention from doctors, nurses, and social workers, and there are strict regulations giving you certain rights (ie you can’t be denied necessities of daily living and you can’t be locked up in any kind of restraints or solitary confinement without extremely good documentation that you are very dangerous). Psychiatric patients cannot be given non-emergency medication or other treatment against their wishes without a court order; psychiatrists are usually very good at pressuring patients to take medications in some kind of tricky ways, but in practice few of them will go through the difficulty of trying to get the court order unless the patient is extremely dangerous. People who complain about psychiatric hospitals most often complain that they are noisy (true), that they can’t leave when they want to (true), and that they are around some scary people (true, though very few are actually violent). Good psychiatric hospitals will have procedures in place for trying to minimize these problems; for example, there is a big movement to switch to private rooms. In my experience most suicidal depressed patients who go to a psychiatric hospital become less suicidal very quickly, end up on a good regimen of appropriate antidepressant medication, and are glad they went.

About a third of patients will recover completely on their first antidepressant within three months. Another third will get somewhat better (>50% decrease on some test of depressive symptoms). Another third will have no benefit.

But outcomes get better the more stuff you try. According to STAR*D, which tested an algorithm a lot like the one I mentioned above, by the last step of the algorithm 70% of patients experienced complete remission, and many more experienced significant symptom reduction.

This is not a resounding victory, because the average depressive episode only lasts six months and the study took more than six months to complete, which makes it really hard to figure out how much of the improvement was due to the drugs. The answer appears to be “some, maybe”. But I will add that patients who recovered because of the study drugs had decreased chance of relapse compared to patients who recover by waiting it out.

I think the important lesson here is that with sufficient work depression either is treatable, or it will go away on its own before you get a chance to finish the treatment algorithm, which is annoying for researchers but probably pretty acceptable to the patient. And once it does, you know what drug works for you, you can sometimes stay on it to decrease chance of relapse (maintenance treatment is a totally different ball game I’m not getting into here) and you can restart first thing when you start feeling depressed again.

The most important thing I’m writing this for, and the lesson I want to hammer home, is that if your doctor just gives you an SSRI and tells you to stay on it even when it clearly isn’t working, there are other options. If your depression is seriously impacting your life, you should explore them, either with your doctor or with a replacement doctor who is more willing to help or – if necessary – on your own.

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239 Responses to Things That Sometimes Help If You Have Depression

  1. Ialdabaoth says:

    Instead, I would eat a lot of fish. The degree to which the level of depression in a country correlates with the amount of fish eaten in that country is staggering. Two salmon dishes a week ought to be a good start.

    Not to turn the whole comment section into a recipe exchange, but…. oh, heck. Let’s turn this chunk of the comment section into a recipe exchange.

    Here’s two fish recipes that I swear by:


    Pineapple-glazed salmon:

    Go to the store, get a small can of pineapple chunks in pineapple sauce (NOT in HFCS ew ew ew), a shaker of garlic salt if you don’t already have one, honey, and a nice slice of salmon.

    Preheat oven to 425. Drop salmon on a sheet of aluminum foil. Shake some garlic salt on it. Then drizzle some honey. Then scoop on a few spoonfuls of pineapple (make sure to get some of the sauce on there too). This whole preparation process takes like, three minutes, which is a BIG FRICKIN’ DEAL when you’re depressed and everything is terrible and you literally have to slither into the kitchen on your belly like a snake because getting up is just too much effort.

    …but I digress. Anyway, slap it in the oven for about 30 minutes or so. For a side, you can get these great bags of broccoli; if not, just get one of the sealable sandwich bags and toss in some tossed broccoli and baby carrots and shake it together for like, 15 seconds with some more garlic salt and maybe two tablespoons of water. Then toss it in the microwave for about 60 seconds. Sure, the bag will maybe get some PCB’s into the broccoli, but when your brain’s red ‘LOW CHARGE – CRITICAL’ light has been blinking for the past 36 hours, just eating SOMETHING delicious and non-terrible is more important than anything else.

    Anyway, you just blew like, three and a half minutes worth of prep on a delicious two-course meal. In my own internal metrics, that’s like, half a spoon spent on +3 spoons tomorrow. Future You will thank you.


    Seared tuna steak:

    If you’re feeling up to expending 10+ minutes on your dinner, grab yourself an ahi tuna steak, some soy sauce, and some wasabi. Get a little cup and mix in about an eighth teaspoon of wasabi with maybe a quarter cup of soy sauce, then pour it all over the tuna steak. Get a little frying pan, drop it on the stovetop on medium heat, and start searing the tuna on each side. If you had to get the tuna frozen, keep searing until the inside of the tuna is pink, otherwise you can afford to leave the middle a ruby-red.

    I find this one is better when I have enough energy to focus on cooking, but forgot to eat. It’s great in that it only takes 15 minutes or so to prep and cook, but you do have to be present and attentive the whole way through, so the glazed salmon works out a bit better when you just need to lie down and hide in a pillow-fort until the aroma compels you.

    There’s my token offering. In exchange, anyone wanna post a good recipe for seasoned tilapia?

    • Ialdabaoth says:

      Oh! A follow-up dietary thing:

      If you’re willing to eat mammals, and find steak delicious, I heartily recommend beefalo for the following reasons:

      – It is the most delicious beef-like steak ever. Seriously, it’s like someone took beef flavor and beef texture and concentrated it into SUPERBEEF.

      – Buffalo are huge and surly, and do not put up with the same kind of crap that cows do. Therefore, they tend to be treated better (as I understand it), because shoving them into little pens and trying to fatten them up will result in demolished pens and smashed feeders.

      – Because buffalo are almost invariably free-range (see above), they tend to have a much more favorable omega-3 load. Not QUITE at fish level, but certainly higher than most supermarket meats.

      So, if you can find good beeffalo steaks, and you don’t have Pinkerian objections to consuming them, give ’em a try. They’re AMAZING.

      • Ian Osmond says:

        Many of those benefits also exist for any genuinely-pasture raised beef — I don’t know of a head-to-head comparison, but I bet that most of the advantage of bison over factory-farmed cattle is the “pasture vs. factory” thing, more than the “bison vs cattle” thing.

        I am under the impression that bison is leaner than cattle, though, which may be relevant. Which way the advantage lies depends on whether you like your meat leaner or fattier, of course.

      • Douglas Knight says:

        Pinkerian vegetarianism = anorexia?

    • For a depressed person who doesn’t want to cook I strongly recommend cans of smoked herring. Taste a lot better than canned salmon or sardines, much lower mercury content than tuna, very cheap, very fatty like salmon.

      • Nisan says:

        I can also strongly recommend cans of smoked herring, and want to add that they’re often called “tins of kippers”.

      • Nornagest says:

        I’ve heard that preserved meats are considered harmful. Do you know if that extends to preserved fish?

        • Ialdabaoth says:

          I’ve also heard, specifically, that preserving fish tends to destroy all the omega-3 fatty acids.

          (For me it’s a non-issue, as I have a severe psychological revulsion towards canned foods).


          Now as to whether the health benefits outweigh the potentially negative effect of eating a processed fish rather than normal fish, I simply don’t know.

        • nydwracu says:

          Preserved meats are considered harmful? The sodium, or?

          I eat kipper for breakfast most days. Can’t be bothered to prepare anything that requires effort in the morning.

        • Alrenous says:


          They did yet another study finding RED MEAT BAD TWO LEGS GOOD, but then someone disaggregated it by sausages and bacon versus steaks and chuck, and found the association only holds for the former. As far as I know it was just the one study because, you know, two legs good, so we don’t really know anything yet.

        • anon1 says:

          Nitrates might explain a difference. I believe they are commonly used in bacon and sausage but not in preserved fish.

      • Lavendar bubble tea says:

        Does anyone else have any recommends for people who are depressed and cannot or do not want to cook(and want/need to change their diet)? I have to admit, maintenance of daily chores is one of the first things that goes to hell for me during a depressive cycle.

        • Ialdabaoth says:

          Does anyone else have any recommends for people who are depressed and cannot or do not want to cook(and want/need to change their diet)? I have to admit, maintenance of daily chores is one of the first things that goes to hell for me during a depressive cycle.

          The ONLY thing that’s helped me in this situation is the buddy system.

          There have been enough times in my life where I needed help and none was there, AND enough times in my life when I needed help and it was provided, that I’ve experienced first-hand how profoundly important it is to surround yourself with people who understand and who want to help.

          The trick, often, is to be willing to accept help, consistently and without judgment, with the understanding that it might be six months or so before you’re able to stand on your own, and even longer before you’re able to repay.

          Good people will understand that this is an investment, and will be there for you.

        • Sarah says:

          If you have the cash, eat out. Or order delivery. Or get deli prepared foods.

          If you need to make actual food, look at Low Spoon Food (

          I am the world’s least domestic person. I buy a lot of sandwiches at cafes. My go-to’s for home-prepared food are:
          bread and cheese
          canned soup
          *sometimes* easy-to-saute meat and fish (sausages, fish filets)

          Protein is necessary for life, and it’s the first thing to go when you lose the energy to prepare food. I’ve been so sad I didn’t want to eat, and I lived on rice cakes, and my hair started falling out. You do not want to do this. Think eggs, canned tuna, canned beans, cottage cheese. Lunch meat. If it needs to be mindless finger food, get beef jerky or chip beef.

        • Lavendar bubble tea says:

          @Sarah- I tend to drink/use protein drinks like Ensure when I have a hard time eating.

        • ozymandias says:

          This may be helpful to you.

        • F. says:

          I think instant mashed potatoes are useful.

          Especially if they have no other ingredient in them other than potatoes, they can be very healthy – just like ordinary potatoes. They need almost no preparation and you can live almost entirely off potatoes, like traditional Irish people.

          If you are depressed, I really hope that you consider green broth; I wrote a long post about that elsewhere in this thread; it’s rather easy to make and very beneficial.

    • roystgnr says:

      How much of the soy/wasabi actually sticks to the tuna? That sounds like a fairly thin ratio, but you didn’t mention any marinating time.

      My go-to recipe for white fish is now:

      Mix a few tablespoons of mayo with a few of lime juice, add in spices (dill, salt, black pepper, old bay), drizzle on fish. Top with breadcrumbs, sprinkle with melted butter, bake.

      Fantastic on cod. Haven’t tried on tilapia, but only thing I’d adjust would probably be to go lighter on the bread crumbs+butter for the thinner filets.

      • Ialdabaoth says:

        the soy actually soaks in reasonably quickly.

        Although I must admit, when I’m in a hurry I don’t even bother with that process – I just squirt some soy right on the tuna directly from the bottle, then smear some wasabi over the top of it and flip it over to let the hot skillet rub it in.

    • Roxolan says:

      This is useful and motivating. Thank you.

    • Eli says:

      Damnit, now I’m trying to remember the recipe for Moroccan fish in pepper reduction I once knew. And for Nile Perch tagine.

      It’s been a while since I had the space to make either of those. Hmmm….

    • Salads Make Me Happy, Political Debates Make Me Bored says:

      As someone hoping to become a vegetarian soon, but who also has experienced severe depression, I endorse threads meant to share recipes on Slate Star Codex, even ones including recipes for the delicious cooking of tragically oppressed buffalo. This is because such threads are much better than others. I’m tempted to write an app that replaces all comment threads on posts tagged race/gender/etc. with recipes.

      • nydwracu says:

        I’d write up some recipes if they were relevant…

        …does fish sauce have omega-3?

        On second thought, it’s probably better for everyone if I never give any sort of food advice.

        • anon1 says:

          Fish sauce is pretty much a straight aqueous solution, with no emulsified fatty component, so no.

      • speedwell says:

        The best vegetarian source of omega-3s is fresh flaxseed oil or fresh flaxseed itself, but since it goes rancid very quickly, the best thing you can do is to buy the whole seed and store it in your freezer, then grind it in a coffee mill as needed. Fortunately a portion of finely ground flaxseed mixed with a little water (you can find the exact proportions online) is a perfect vegetarian egg substitute in baking and other recipes, so you can get plenty in that way,

    • Tab Atkins says:

      I put together a recipe webapp some time ago for my wife and I. There’s some hidden functionality (hidden because I’m too lazy to make it work safely multi-user) that lets you create weekly menus and generate grocery lists from it, but the public version at least lets you manually select recipes and generate a grocery list. (The ingredient deduping needs to be improved, but it’s adequate a lot of the time.)

      We’re vegetarian at home, so most of the recipes in there are vegetarian as well. Hopefully this will be helpful to someone else!

  2. Multiheaded says:

    Absolutely obligatory link to ye olde Allie Brosh post for identifying depression. Scientismically approved!

  3. Cyan says:

    Some antidepressants have discontinuation syndromes, which mean you feel sick when you’re withdrawing from them. Effexor (venlafaxine) [is] particularly bad.

    Holy fuck can I ever testify to that.

    • Julia says:

      My mom forgot to bring hers when we traveled out of state for Christmas one year. Worst Christmas.

    • Zorgon says:

      Oh boy and then some.

      Probably the single worst discontinuation issue I’ve had common to nearly every SSRI I’ve been on has been the “head-zaps”. Short, intense buzzing-like sensations inside the head, usually in clusters, typically triggered by any gross eye movement. Typically lasting a month, although the worst case I ever had lasted three.

      In comparison, headaches, insomnia and sexual dysfunction were all kinda minor. I’ve never felt anything like it. Just horrible.

      • anon says:

        I get head zaps when starting a new antidepressant, not stopping. And they’re pleasant, if anything. Huh.

      • Douglas Knight says:

        Are you comparing a month of head-zaps to a month of side-effects? Why would you do that, since they are not a side-effect, but a temporary effect? Isn’t the question whether this bad month is worth the knowledge gained by testing another drug? Roughly speaking, comparing a month of head-zaps to a lifetime of depression or side-effects?

        Moreover, have you tried tapering off of SSRIs? Does that help?

        • Zorgon says:

          Nope, tapering has never helped. They show up either after or just before the last dosage interval.

          As for the comparison – it should be fairly evident from the implicit plural of SSRIs I’ve been on over the years that the fairly reliable incidence of “head-zaps” hasn’t actively prevented me from trying different formulations, mainly because of exactly that internal comparison and because as uncomfortable as may be (for me, thanks lucky anon) they’re significantly less debilitating than a continuing depressive episode.

          But if I had to point to any particular perceived negative to a renewed course of them, the potential for “head-zaps” on discontinuation would definitely rank above pretty much any of the ongoing side-effects. All of those are comparatively rather unobtrusive, while my own particular “head-zaps” tend to be strong, painful or near-painful, highly distracting (often ruining whatever train of thought I’m in) and cluster together in groups of 3-5 depending on how far into withdrawal I am.

          I would like to reinforce for anyone reading, btw, that severe discontinuation effects of this kind are not universal and I’d not suggest for a moment that anyone avoid SSRIs for this reason. I just have another factor to consider when deciding whether to take them.

          Brains, it turns out, are weird. Who knew?

    • anodognosic says:

      Someone I know had some pretty bad venlafaxine withdrawal symptoms until she took psylocibe mushrooms. She said it pretty much made the brain zaps and the nausea go away.

  4. macro minimizer says:

    Thanks for this.

    What are your thoughts on supplementing with 5-HTP?

    • IANAD but my understanding is that 5HTP is inferior to tryptophan for depression because most of the serotonin synthesis will happen in your gut instead of in your brain due to inability to pass the blood brain barrier. Tryptophan metabolizes to serotonin and melatonin and can pass the blood brain barrier. I’ve had friends have success with tryptophan helping their sleep and anxiety. It might not help significantly though. Unfortunately the issue is rarely as simple as “more of neurotransmitter X”.

      • speedwell says:

        I tried tryptophan but did not get any significant result, plus there is some evidence that it can cause people with a family history of diabetes to develop the disease, so I discontinued it.

        Anyway I was referred to a psychiatrist who said I “couldn’t” be having the rare side effects I was having to SSRIs, despite the fact that others noticed my lethargy and behavioral changes, and also using 5-HTP or St. John’s Wort just gave me unmistakable serotonin sickness at any recommended dosage, so I possibly don’t need a medication that works on serotonin. Medications that increase dopamine work better on me, but I quite agree that it is not as simple as “more of neurotransmitter X”.

      • macro minimizer says:

        Interesting. I’ve actually had success treating my own depression by taking 5-HTP (along with fish oil and EGCG, which I’ve read slows serotonin production in your gut).

        I realize that everyone is different, and I haven’t yet had the bravery to experiment on myself and see if it’s the placebo effect in action. I also haven’t tried [l-]tryptophan.

    • macro minimizer says:

      Thanks again. I was just thinking about how hard it is to find this kind of information online presented in such a straightforward, comprehensive, and trustworthy way.

      If you’re up for it, I’d be very interested in reading a similar guide for ADHD.

  5. Doug S. says:

    In the old days, they used morphine as a treatment for depression because they didn’t have anything else. It did work, but opiates have all kinds of problems that makes them the same kind of last resort as electroconvulsive therapy. (And forget about black market opiates such as heroin. You won’t be able to get your hands on the kind of consistent doses of unadulterated active ingredient that will let you live a normal life instead of turning you into someone else’s horrible warning.)

    Deep brain stimulation implants are another thing that sometimes seems to help (evidence of effectiveness is mixed), but they’re also another last resort because getting one involves people opening up your skull and poking at your brain while praying that they don’t accidentally break anything.

  6. Andrew Hunter says:

    Can you suggest what to say to a psychiatrist to convince him to proscribe *finil? I have interest in trying it (in particular, I believe I have and found some papers on its use there); my GP said he liked the idea but was hesitant to write off-label psychiatric drugs himself and instead referred me to one of the psychiatrists in his practice. What are good things to say to talk the psychiatrist into being open to the idea? (I’m not willing to try, despite your arguments above, most standard anti-depressants; I’m too concerned about placebo/sideffects/discontinuation.)

    Alternatively, supposing hypothetically I was going to buy it myself without the scrip, where would you do that? You said you liked nootropicsdepot, but I have (probably irrational) fears about the safety of drugs bought anywhere but from, like, an Official US Pharmacy. (Wow, even writing that down makes it sound like a stupid concern.)

    • Scott Alexander says:

      I would show them the papers you found, mention that it’s worked for friends of yours, and talk about your symptoms of fatigue and decreased energy. If you have some kind of shift-work that makes you work odd hours, definitely bring that up.

      I can’t think of any way you can get it from an Official US Pharmacy without a prescription. Your best route might be to get the adrafinil, which is at least produced by US-based supplement makers and is much the same. Alternately, is a subreddit dedicated to pretty much this question and has a lot of resources on it.

      • Andrew Hunter says:


        Do you have any other advice or knowledge worth mentioning about specifically atypical depression? (I hit the symptom cluster on Wiki right in the nose.)

        • Scott Alexander says:

          Not really. There are vague rumors that MAOIs are unusually effective in atypical depression, but the evidence is weak. Might want to talk to your psychiatrist about it if nothing else works.

  7. THANK YOU THANK YOU THANK YOU for making this. When researching lifestyle interventions to increase longevity I grappled with the section on suicide and depression. Even though it is a significant risk for young people I didn’t feel qualified to go into specific recommendations. It felt like a serious hole in the material that bugged me. This post could be a massive help for people who are very fearful of seeking official help. Any road map is much better than no map at all when you’re lost and scared. I think this line deserves to be a giant headline in bold: “outcomes get better the more stuff you try”

  8. zz says:

    When I was in college, I took a course called “drugs, brain, and behavior” on the effect of drugs on the brain and behavior (no, really?). It’s done some wonderful things in terms of reducing inferential distances whenever a doctor is setting me up on a drug. Unfortunately, this class was some time ago, and I wasn’t using Anki at the time, so I’ve forgotten a bunch of stuff. Can you recommend a good pharmacology textbook that makes sense for someone wanting short inferential distances when learning about a new drug (as opposed to a book that makes sense for someone wanting to prescribe drugs to other people)?

    • Scott Alexander says:

      I’m sorry, no. I use Stahl’s “The Prescribers Guide” and like it, but that’s obviously for prescribers. is a website a lot of people say good things about.

  9. Amianym says:

    you can’t be locked up in any kind of restraints or solitary confinement without extremely good documentation that you are very dangerous). Psychiatric patients cannot be given non-emergency medication or other treatment against their wishes without a court order

    Maybe the laws are different with adolescents (I was 14 at the time), but this was not my experience when I was hospitalized. One night, I was confined to a room and made to choose between taking a medication “voluntarily” or forcibly, for reasons that multiple staff members later agreed were stupid. The next night, when I got angry because I didn’t want to take a medication my psychiatrist hadn’t talked to me about and seemed like it had serious side effects, the staff were at best not bothering with deescalation, I did something violent, and was restrained and forcibly drugged, being watched by the staff person that I had asked not to interact with. She seemed disappointed that she was legally obligated to let me out after an hour.

    The ensuing PTSD was not particularly helpful.

    also uh, such list, very gratitude!

    • Scott Alexander says:

      You can definitely be forcibly confined and drugged if you’re violent, or something that can be rounded off to “threatening violence” (such as yelling at people really loud and refusing to stop). They will just do the documentation saying you are very dangerous.

      I am not sure about the laws with adolescents, but I do wonder whether the choice of voluntarily or forcibly was part of what I meant when I said psychiatrists are very good at tricking you into taking drugs voluntarily. I could definitely imagine somebody saying that when they don’t actually have the legal muscle to make you take the drug forcibly.

      But if the adolescent laws are different (and I bet they are, especially if your parents consented for you), the laws in your state/country are different, or this was after you did something they could round off to threatening violence, then it’s possible they did have the legal muscle.

  10. US says:

    I only skimmed the post and I’ll probably read all of it later, but an important aspect I did not see mentioned in the post is this: People suffering chronic illnesses such as e.g. diabetes may often – much more often than people in general – have a form of subclinical depression that does not meet the diagnostic criteria for major depression. The fact that depressive symptoms in these cases often do not meet the diagnostic criteria for major depression does not mean that they’re irrelevant or that they should be disregarded, and it seems that the medical field is beginning to pay more attention to such aspects of chronic illness, in part but not only because such aspects relate to treatment aspects like compliance/adherence.

    I covered a textbook dealing with these things on my blog not too long ago – if you’re interested, you can read more about this stuff here.

    • speedwell says:

      I am a prediabetic and my depression is strongly linked to my insulin resistance as far as I can tell. Blood sugar levels and insulin production are tied to cortisol, which makes me anxious and ruins my sleep. I also have to be vigilant about both supplements and prescriptions because it is rare for someone to understand the reactions between sugar metabolism and substances often used for depression. I find that magnesium (it must be a bioavailable form such as citrate rather than the useless oxide form) helps for both sleep and blood sugar regulation; I also tested low in magnesium when they did blood tests. I take 1000 mg of extended-release metformin per day for insulin resistance, blood sugar control, possible PCOS, and as protection for a family history of breast cancer. I found a past study that showed that several sufferers of depression so severe that they couldn’t function were helped by metformin, which is suggestive and probably worth further study. Diabetes is linked in my family and in other studies to autoimmune illnesses such as RA, vasculitis, and sarcoidosis, and sleep disorders such as narcolepsy, tooth grinding, and sleep apnea, and it is not impossible that autoimmunity issues and sleep problems generally are behind a lot of the depression and anxiety that also runs in the family.

      The amino acid L-theanine works very well for me, and helped me find my way to a short remission a few years ago. When I am suffering a severe bout of fear, pain, and unreasonable crying, I accidentally discovered that a combination of a gram of magnesium citrate, 600 mg of L-theanine, and a 24-hour loratidine (Claritin in the US) gives me significant relief within two hours. I have no idea at all why the trio works like this, but I have tried leaving one component or another out and it didn’t work as well if at all.

      I can’t rule out, at the age of 47, the possible role of perimenopause in all of this. Some women get well and truly messed up during and after “the change”.

      I found a good therapist who helped me learn a truckload of cognitive coping skills that I had never picked up while growing up as a lonely girl geek in a dysfunctional family. I now have tools for positive and realistic thinking that helped me overcome depression again and prevent relapse. I can’t recommend any particular tools because I suspect they are just part of a normal pattern of healthy positive thinking.

      Anyway, those are just some thoughts I wanted to pass on. Thanks. 🙂

      • US says:

        “Blood sugar and insulin production is tied to cortisol, which makes me anxious and ruins my sleep”

        I’m not completely sure how to interpret this, but I figured I should point out as a general point that whereas I don’t think anybody questions that day-to-day or hour-to-hour variation in mood can be linked to glycemic control and related stuff, such aspects are not really related to the subclinical depression stuff they talk about in the book, except in the sense that they’re potential confounders.

        It was kind of you to share those thoughts. I’ve been type 1 almost my entire life (I’m 28) and the book I review in the link is ‘sort of relevant’, as one might euphemistically put it. I tried to kill myself five years ago or so and I still consider it one of the most likely ways for me to die. It’s not really something I want to talk about, just thought I should reciprocate given what you’d told me.

  11. Joe says:

    Is there any truth to the idea that a sexually licentious lifestyle leads to depression and suicidal ideation? I remember learning about Romanesque capitals and one in particular showed a demon having sex with a woman on one side of the capital the other side showed the demon stabbing himself. The instructer said this was ment to teach people that lots of sex was self destructive

    • Ialdabaoth says:

      I’m fairly certain that, if there is a causative link, it goes the other way.

      I.e., people with the sorts of neurochemistry and environment that leads to depression and suicidal ideation, will also tend to develop more flavorful sexual behaviors.

    • ozymandias says:

      My particular sort of crazy, borderline personality disorder, is linked to sexually promiscuous behavior and to suicidal ideation. However, the sexual promiscuity is a product of mental illness rather than a cause of it. Specifically, borderlines tend to have poor impulse control, massive fear of rejection which makes it hard to say no, and a desire for validation which it is really easy to use sex to fill.

      • Ialdabaoth says:

        {bare signal of sympathy and pseudo-solidarity}

        • Joe says:

          You have my sympathy as well as my prayers Ozy. I wonder if the behavior and the disease may have a cyclical causation? Does the behavior exasperate the illness?

        • ozymandias says:

          IME my times of relatively high promiscuity and relatively high functioning seem pretty correlated, but that may be because I’m also socially phobic and promiscuity generally requires scary things like “leaving the house.” I haven’t noticed any particular negative effects from promiscuity personally, but it is probable that a sex-positive social circle and the fact that I don’t fall in love after I have sex are protective factors. I suspect an unplanned pregnancy, social disapproval, etc. would be pretty bad for one’s mental health.

      • Ialdabaoth says:

        You have my sympathy as well as my prayers Ozy. I wonder if the behavior and the disease may have a cyclical causation? Does the behavior exasperate the illness?

        That doesn’t actually seem to be the case for most people. Actually, it seems to be the opposite more often than not – lack of sexual intimacy and fulfillment seems to trigger people’s depression.

        Also, as ozy mentioned, social disapproval of one’s “sexually licentious lifestyle” can also be pretty nasty.

        • Joe says:

          It would be interesting to know which came first, the sexualized mental illness or societal disapproval. I mean that anthropolgicaly not in Ozys life.

        • ozymandias says:

          I suspect social disapproval is probably mostly caused by a society without birth control rather than by borderlines and bipolar people.

        • Joe says:

          I agree. But I imagine many people intuit that promiscuity is symptomatic of mental instability and therefore avoid that behavior or avoid people people that engage in it.

        • Ialdabaoth says:

          > I agree.

          I notice that I am confused.

        • Joe says:

          I was agreeing with Ozy that fear of unwanted pregnancy was the primary cause of sociatial disapproval of promiscuity, but I suggest that the fear of signaling mental instability is a good secondary reason.

    • Lavendar bubble tea says:

      I think it’s a fairly complex matter with many potential variables. I don’t know/think (and currently doubt) that people who have lots of healthy consensual sexual exchanges with low/no chance of unwanted pregnancy are going to emotionally suffer for it/that it is a health risk. Having a healthy sexuality has many benefits.

      However, if a person is in a culture which strict taboos against sexuality, is not using protection/is at STI risk, is at risk for unwanted pregnancy or is involved with people who are not emotionally healthy for them to be around, then there is a higher chance of their overall life enjoyment decreasing or possibly creating suicidal thoughts/intense hopelessness. I don’t think this innate to sexual expression, but is an issue of potential complications not being minimized.

      On a personal note, I have seen several people in my life use alternative sexuality and polyamory in really unhealthy ways that were either abusive to others or overly complex self harm. (One person I know defined their previous actions as the latter) Most if not all of these cases were people bringing pre existing issues into their sexuality, as opposed to these issues having been solely created by alternative sexual expression.

      Basically, I suspect that a lot of issues can be caused by or intensified by unhealthy sexual behaviors, but I do not think that non monogamy/alternative sexual expressions are inherently unhealthy/are going to be the sole cause of depression and suicidal thoughts. I hope that I helped to answer your inquiry.

    • Julia says:

      Someone with bipolar might have manic periods when they have a lot of casual sex and and depressive periods when they feel suicidal.

    • Scott Alexander says:

      I’ve never heard anything about this.

      Romanesque capitals are generally placed on the lowest level of medical evidence, along with case studies and cross-sectional data.

    • Phil Goetz says:

      I know many more men who are depressed from having too little sex than from having too much. I didn’t count, but my impression is that lack of sex is the most-common and most frequently-mentioned correlate of clinical depression in males. When I say lack, I mean a total lack of sex for many years, despite continual attempts to get it.

  12. ADifferentAnonymous says:

    Some questions about applicability:
    How much of this advice applies to depression other than MDD?

    What about anxiety? Does its presence alongside depression alter any of the above?

    And lastly, do small hypomanic episodes about once a year (but not on a regular schedule) put one into the completely-different bipolar bucket?

    • speedwell says:

      I actually do have anxiety as a symptom of depression. I thought my therapist was nuts when she said this, but I did some reading on my own and found to my surprise that it is often so. Perhaps that’s why the L-theanine helps me so much; it works on dopamine and directly reduces anxiety, which stops me from spinning my wheels uselessly and frees me to use my mental energy to pull myself out of the hole.

    • Error says:

      What about anxiety? Does its presence alongside depression alter any of the above?

      I second this question.

    • Scott Alexander says:

      Probably applies poorly to depression other than MDD.

      Anxiety doesn’t change too much. Treating the depression won’t necessarily treat the anxiety (though it might help) and vice versa. The biggest change might be suggesting depression treatments that are also effective against anxiety – for example, the SSRI Paxil or the atypical antipsychotic Seroquel. I would also recommend the supplement theanine.

      I think you’d get different opinions from different people about your small hypomanic episodes (and they would ALL demand a much more detailed history). Some people, if the more detailed history made them think it really might be bipolar, might think it was worth trying lamotrigine or Seroquel, which are more commonly used in bipolar depression.

      • ADifferentAnonymous says:

        Well, they aren’t my small hypomanic episodes, but based on the above I’m going to go with ‘the pros probably handled it pretty well’ rather than ‘omg they should be treating you for bipolar not depression that’s why you’re still sad a lot!’

        More green tea is a nice prescription, though.

  13. Anonymous says:

    As strange as it sounds, caffeine was probably the most effective drug I’ve taken for depression (in terms of benefit vs costs). It gives me enough energy to work through things. The problem is I feel a bit worse on days where I don’t use it. But even after years of use, I still feel less-depressed than when I didn’t use it, or when I’m taking a break (even two weeks of no caffeine doesn’t make me feel better, so it’s not withdrawal).
    I take anywhere from 200 – 300mg / day.

    • Anon2 says:

      I second the suggestion of caffeine. My theory on why it works is because depression is an inflammatory disease and caffeine is a methylxanthine which have anti-inflammatory properties.

    • Phil Goetz says:

      I get headaches if I go without caffeine, but I’m starting to think taking energy drinks like Red Bull regularly causes me more problems than caffeine on days when I skip them. Note that different energy drinks have different active ingredients and different artificial sweeteners.

  14. Alexander Stanislaw says:

    I’m not depressed but my mood is somewhat on the sluggish end. I’m considering using CBT to elevate my mood. Do you know if Feeling Good by David Burns is comparable to the CBT book you recommended? I already have it on my Kindle. I might just by your recommended book since Burns is a bit theoretical. Has anyone you know who isn’t clinically depressed tried CBT?

  15. nydwracu says:

    Smokers have more than twice the rate of depression than nonsmokers. There’s a lot of debate about whether it’s causal or noncausal, but some sophisticated statistical modeling seems to suggest there is indeed a real link.

    Tobacco apparently has MAOIs, but I’m not sure if the amount is large enough to be relevant. I’ve never heard of tobacco causing the nasty things MAOIs cause.

    Subjectively, tobacco seems to help with my thing-that-may-or-may-not-be-depression. I haven’t had my e-cig for long enough to get an intuitive feel for whether it’s better or worse than snus, so I don’t know if it’s nicotine alone or nicotine plus the other chemicals in tobacco.

    I also can’t compare snus to cigarettes, but that’s just because cigarettes have next to no effect on me that isn’t probably caused by the ritual of smoking. Back when I smoked, I rarely managed to make it through a pack before they went stale — it was two a day at most, and sometimes I’d just forget. I’m not really sure why there was such a large difference.

    Anyway, my guess is that it’s causal in the opposite direction: people with depression are more likely to start smoking.

    There are other possible reasons than the chemicals: smoking is prosocial and depression leads to less social interaction so people with it take the prosociality (I did this in my freshman year, at a college where there was a Schelling-point smoking area, but not after I transferred); it’s an excuse to get up and go outside and getting up and going outside is a useful way to break a period of inactivity; maybe depression correlates with some personality trait that makes people more likely to take up new things, including smoking…

  16. Matthew says:

    Interesting not to see anything about loneliness and social isolation in there. It seems to me that depression often features a vicious cycle where being lonely or socially isolated makes one depressed, which then makes one isolate oneself further.

    I’ve noticed mildly beneficial effects from Seth Roberts’ morning faces suggestion, though the effect isn’t big enough for me to be sure I’m not just fooling myself.


    On a possibly-separate note, I found the bipolar description kind of interesting. I realize it’s a not real thing, but I feel like I have “relationship status-mediated bipolar disorder” — when I have the attention of a woman I’m Al Fulani-ed to, I have that entire list of manic symptoms, except for shortened temper — rage born of despair is actually associated with the lows, not the highs. When said woman loses interest, I end up in what would almost certainly be major depression if I wasn’t countering it with what most would consider impractical amounts of exercise, until falling under someone else’s spell. This cycle has been continuous for almost a year now: lovestruck/manic in July/August 2013 and December/January 2014 and rejected/depressed between and since.

    • US says:

      The first part is potentially important, i.e. that including the social isolation variable in the analysis may make a lot of sense. It should perhaps in relation to that also be pointed out that this aspect can actually be specifically addressed through therapeutical approaches, and that there’s some evidence that interventions aimed at improvements in that area work at least for some people:

      “In summary, meta-analysis of the randomized group comparison studies revealed a small but significant effect of the interventions on loneliness. Of note, interventions that addressed maladaptive social cognition had a sizable mean effect compared to the other intervention types.”

      From this post, which has more. See incidentally also this study; being lonely seems to be rather unhealthy even if you’re not depressed.

      • Matthew says:

        80% of waking hours in the company of other people?!

        In a typical day I doubt I spend 20% of my time in the company of others, and if we limit it people my own age (i.e., not my children), it’s probably more like less than 5% of my waking hours in a typical day.

        • Julia says:

          For someone whose job involves a lot of people contact, 80% would be easy. My husband got happier when he moved from a workplace where he had his own office to one with an open floorplan. (Though that would drive some people crazy.)

    • anon says:

      I desperately need social contact, but also suffer from the System 1 belief most people dislike me. System 2 says they’re only indifferent towards me, which feels almost just as bad. My social skills are actually above average when I’m using them but it takes a lot of focus out of me, and I only ever use them in situations where I’m forced to. I never pursue social things on my own, I am afraid, lack willpower, and don’t know how due to lack of experience.

      I would love a post on how to magically get social contact or the benefits of social contact.

  17. Sarah says:

    Thank you so much! This is really useful!

    I wish someone had told me about SLEEP! a long time ago.

    I no longer have the black periods I think of as depression. (I never got a diagnosis, but apart from all the suicidal ideation, I couldn’t remember anything I read, I got tunnel vision, and I would fall down just walking down the street.) None of that ever happens now. Ever. Probably, among other things, because I sleep a solid seven hours a night instead of four.

    • Lavendar bubble tea says:

      “. (I never got a diagnosis, but apart from all the suicidal ideation, I couldn’t remember anything I read, I got tunnel vision, and I would fall down just walking down the street.) ”

      I’ve had periods of time where I had an amazingly hard to internalizing what I was reading. It was like my eyes would gloss over the page. I also didn’t get it diagnosed but really wish I knew more about what it was.

    • anon says:

      You were sleeping four? Jesus, if I did that I would be hospitalized in a week. I already feel foggy and unable to focus on only 7. Your body is awesome, I’m jealous!

      • ozymandias says:

        I feel like that was not the lesson you were supposed to get from that anecdote, anon. 😛

        • Sarah says:

          …yeah. I am not the sort of magic person who can function on four hours of sleep. Learned that the hard way. Do not try this at home.

        • anon says:

          Oh oops, I think I expressed myself badly. I meant that it’s impressive that you’re the sort of person who can function on only 7 (as you do now), and at least stay alive on 4. But I realize that that’s an insensitive thing to point out when your comment was about the consequences of sleep deprivation for you. I just dashed it off without thinking — sorry!

  18. Mary says:

    On the anemia side of things:

    You need Vitamin C to absorb iron. Try eating fruit along with your iron-containing dishes to see if the tiredness is anemia. (Assuming it’s not seriously tired and you ought to see the doctor.)

  19. Julia says:

    This is great; thank you for writing it up.

    Note that doctors are not the only ones who can commit people to hospitals. In Massachusetts, you can be committed by a doctor, a psychiatric nurse, a psychologist, or a social worker. So your therapist can probably commit you, too.

  20. Anonymous says:

    Upon reading examine and others, it seems saffron is also fairly toxic and might have its own set of side effects and contraindications (possible blot thinner, traditionally used as an abortifacient as well as an antidepressant, etc)

    (Scott … just in case some pregnant lady reads the blog and starts trying it, maybe add a warning or disclaimer? People have a tendency to let their guard down around natural remedies, especially when they are food ingredients.)

  21. James says:

    Do you have particular recommendations for dysthymia?

  22. Lila says:

    Maybe I’m misreading this, but you seem to subscribe to what I call the “biological theory of depression”. Basically, a lot of people talk about depression as if the brain simply breaks down for no reason, just a “chemical imbalance”. Which seems nuts that this would happen in millions of otherwise healthy young people. The other vital systems of young people don’t simply break down for no reason, except in people with rare congenital defects. So there must be some environmental factors. In my experience these are usually social/situational/personality-related, but they could also be diet-related, etc. So antidepressants just treat the symptoms, not the cause.

    People hate when I use the term “happy pills”, and I agree it’s a loaded phrase, so I’ll stop using it. The common response to the “happy pills” thing is that taking antidepressants is different from getting high. The way antidepressant use is commonly described is a subtle brightening of mood, greater optimism, etc. Like it’s a very smooth transition, rather than the spike of a high. I’ve never taken antidepressants for a long enough period to get a positive effect, but that description sounds _exactly_ like being moderately high on Vicodin, which I’ve experienced. Just because you don’t think you’re Jesus when you’re high doesn’t mean you’re not high. It’s just a different flavor. Obviously antidepressants are way safer and less addictive than Vicodin (though read up on this: But I think it’s a bit deceptive to describe them as a cure rather than a distraction.

    • Amianym says:

      Having been on various antidepressants and on opioids, I can say that they feel very different. The effect I got from antidepressants was not exactly a “brightening of mood”; it was more like I could interact socially without being preoccupied with my conviction that everyone hates me and I can’t possibly say anything of value. To use an analogy, it was more like suddenly ceasing to get punched in the face than like being handed a slice of cake. On the other hand, I’d use the same analogy for how I feel on opioids for pain, so make of that what you will.

      • Katie says:

        I’ll second the “ceasing to get punched in the face” description. I’ve never felt anything like a “high” from using antidepressants – the only noticeable effects I’ve experienced are a dampening of negative emotions and a quieting of involuntary self-criticism/self-punishment.

        “Distraction” seems like precisely the wrong word to use to describe them, since they negate (or partially negate) the nagging, attention-draining negative pings that prevent someone like me from getting some mental peace and quiet.

        • speedwell says:

          I’ll third it. When I am having a really bad bout of painful crying, and I take something that I know helps, it is exactly like taking pain reliever for a headache. I still feel depressed, but it isn’t like this pounding, horrible, frightening malfunction, and I can sleep if I want.

          The experience of taking L-theanine for milder depression is more like taking a strong, soothing cup of Irish Breakfast tea, and this is no accident since tea, especially black tea, contains rather a lot of it. It “turns down the volume” on destructive thinking and gives you some room to breathe, or so I’ve found in my own case. The way I described it to my therapist at the time was, “I don’t have to give myself a hard time about it anymore”. Since I was being treated specifically for body dysmorphic disorder, that was a huge win.

        • nydwracu says:

          tea, especially black tea, contains rather a lot of it.

          Doesn’t shade-grown green tea have the most L-theanine? That’s what I’ve heard, and this seems to agree about at least gyokuro.

    • ozymandias says:

      I am not sure why antidepressants would stop people from working on the base problem. Like… if you’re depressed because you don’t have any friends, and can’t get any friends because you’re depressed, becoming less depressed might help you acquire friends. Also, some people are miserable in situations they can’t change, and it seems mean to require them to be miserable forever for no reason.

      At the same time, I’m not really sure why we need to treat the cause. Like, if someone wants to treat the cause, they can knock themselves out– mandatory medication for depression is a dumb idea. But I feel like either the cause has negative effects besides sadness, or it doesn’t. If it doesn’t, then who the fuck cares about treating the cause? You’ve gotten rid of everything bad about it already! If you have seasonal affective disorder and like where you live except that you get sad in the winter, you don’t have to treat the cause and move to Florida, you can just buy a lizard lamp. If it does have negative effects, surely those negative effects are sufficiently motivating without the misery. (And if they’re not, like I said, who cares?) If they have negative effects but the effects are hard to notice– maybe a dietary imbalance causes short-term depression and long-term health problems, and you wouldn’t notice the health problems without the depression– that would be very worrisome, but I see no reason that those can’t be dealt with by having articles like this go “also, if you’re not getting enough of vitamin wtf, you really need to take some” and getting psychiatrists to ask depressed people about their vitamin wtf intake.

      Incidentally, how would your opinion change if SSRIs were entirely placebos?

      • suntzuanime says:

        It seems to me that there are basically two concerns here. Concern #1 is that SSRIs are expensive and have nasty side-effects – Scott, as an asexual, probably does not fully recognize how unpleasant a screwed-up sex drive is as a side effect to most people. It would be nice to not be sad all the time *and* have a working dick, or so I hear from people who have had to make the choice.

        Concern #2 is that drugging people so that their otherwise awful sociomaterial conditions don’t bother them seems sinister to many people. There is a somewhat complex argument to be made about how what you value isn’t just happiness but rather the achievement that goes along with happiness and so wireheading in the form of drugs that make you happy without the achievement is a trap. It’s a colorable argument, but I’m not really the person to make it.

        • Sarah says:

          Gaining weight and having no libido sound awful to someone who’s never been on rougher drugs. They are minor compared to the side effects of *other psychiatric drugs.* Psychiatrists mostly see patients who are in a hospital; when I talk to psychiatrist friends , I find they’re pretty anchored on the experiences of hospital patients. Basically “Dude, your medication is *nothing*. Some people have to deal with tardive dyskinesia.” It’s probably a useful perspective shift, like, if you’re not forced to choose between dangerous psych meds and dangerous mental illness, you’ve got a lot to be thankful for. It doesn’t change the fact that SSRI side effects are undesirable.

        • Scott F says:

          Adding bupropion (Wellbutrin, Zyban) to an SSRI regimen is apparently effective at reversing sexual dysfunction! (It was in my case, and it was implied to me by a psychiatrist that it was common knowledge amongst psychiatrists).

        • Quixote says:

          One thing that’s missing here is that for some people (maybe as many as 1-2%) the side effects of SSRIs are permanent. That is, they NEVER GO AWAY. Or at least they don’t go away over 5-10 years. I know some folks that have had to deal with this and it’s pretty bad. There’s a fairly big collection of support groups and online communities.

          Anyway I think this article is great but SSRIs are more serious and more permanent risky than presented here

      • ADifferentAnonymous says:

        I feel like this is one of those annoying cases where the obvious statement “Don’t let symptom-treatment be an absolute stop that prevents you from even considering cause-treatment”, the contentious-but-plausible “Symptom-treatment often distracts us from worthwhile cause-treatment”, and the downright silly “never treat symptoms because that distracts us from treating causes” all kinda sound the same despite being hugely different.

    • nydwracu says:

      I’ve never taken antidepressants for a long enough period to get a positive effect, but that description sounds _exactly_ like being moderately high on Vicodin, which I’ve experienced.

      So have I and no it doesn’t. Vicodin is everything slows down and you stare at a wall for three hours. Maybe it’s similar in that the internal monologue shuts down, so it’s not there to wreck everything, but it would take even more effort for me to do things while on Vicodin than while in the state that may or may not be depression.

    • Eli says:

      The basic problem is that whether the cause is strictly biological, genetic, or psycho-social, once the brain gets into a clinically depressive state, it is attacking itself. CELL DEATH IS OCCURRING. You need to make the biological own-goal stop before you can treat the other proximate causes of the depression and get better.

      Which doesn’t excuse you from treating the other proximate causes at all. I’ve had to do both.

    • Ian Osmond says:

      Antidepressants don’t make me happy.

      They merely mitigate my inability to feel happiness.

      Depression, for me, includes being completely shut off from a capacity for happiness. Or, indeed, most strong emotions: I can feel a sort of mild grey melancholy, sometimes, and feeling that is something of a relief when I can work it up.

      When my antidepressants are working, they don’t make me happy. But I can react with happiness when something happy happens.

      Or, y’know, anger and offense when someone suggests, even accidentally, that my experiences aren’t real.

    • Scott Alexander says:

      I think it’s probably a very complicated multifactorial thing, but that the brain is a biological system and anything that happens there is going to be biology at some level or other.

      I think whether antidepressants are “solving the problem” versus “covering up the symptoms of the problem” requires complicated philosophy that we might not even have the biology to start working through yet.

      For example, suppose every time you see a bright flash of light, you get a seizure. Your doctor gives you anticonvulsants, and it stops happening. Insofar as the “problem” was seeing too many bright flashes of light, your doctor is covering up the symptoms of the problem. But I would rather phrase this as “your brain has a problem with processing stimuli in an adaptive way, which is being fixed”.

      It seems like a really big part of the puzzle is low levels of BDNF in the brain and low levels of cell growth in the hippocampus. Antidepressants do raise BDNF levels and hippocampal cell growth (so do exercise, good sleep schedules, and ECT). If you asked me to come up with a wild guess theory on what depression is, I’d say that some people have a genetic predisposition to having high levels of stress-induced cortisol secretion start some kind of feedback loop that decreases BDNF. If that’s true, antidepressants are treating the condition.

      Since antidepressants can also prevent relapses of depression, that also makes me think it’s treating the condition rather than superimposing artificial happiness upon it. Also, I don’t hear a lot of stuff about nondepressed people getting happier when they take antidepressants (except sometimes people say that about tianeptine).

      “The other vital systems of young people don’t simply break down for no reason, except in people with rare congenital defects. So there must be some environmental factors. In my experience these are usually social/situational/personality-related, but they could also be diet-related, etc. So antidepressants just treat the symptoms, not the cause.”

      From an evolutionary medicine perspective you are of course right. But let’s look at other conditions that a very large number of people of reproductive age are getting. Obesity, diabetes, ADHD, asthma, autism, myopia – and if you’ll let me be very speculative and without intending to cast the conditions as “disease” or “evil” but just “these are evolutionarily unexpected conditions that we are suddenly finding in a very large number of people” I would add homosexuality and transgender to the list.

      Given modern diet, lack of exercise, stressful living conditions, novel family and childbirth arrangements, exposure to novel toxins, exposure to novel infectious agents, lack of exposure to other infectious agents, and use of medications most likely something evolutionarily unexpected is causing all this stuff to happen (in the case of myopia, we know exactly what it is – kids’ eyes are failing because we get them to start staring at things close to them very early, which is an evolutionarily novel stressor). While I agree it would be wonderful to solve the root problem, we don’t know what the root problem is and if it turns out to be something hard like “diet” or “modern life is stressful” we might not be able to solve it. In the interim, I think medications are a pretty good temporary measure.

    • anon1 says:

      This notion that just treating the symptoms is inherently inferior pisses me off (even though others’ suggestion that of course the environment doesn’t matter ALSO pisses me off). I went to grad school, went from mildly depressed but perfectly functional to quite badly off, and then dropped out and immediately felt better. But suppose I’d really wanted to stay? Would you say that because the root cause of the problem is easily identified and fixed I should give up my goal of being a scientist rather than just treating the symptoms?

    • Anonymous says:

      I’ve been sad about real problems in my life. Those feelings cycled with events – when life got better, my feelings got better.

      I’ve been depressed for 6 months for no reason whatsoever. It wasn’t worse, but it was DIFFERENT. My sleep pattern changed (started waking up way early), my digestion was weird, my body started getting random pains and joint inflammations…and most importantly, my feelings did not fluctuate with life events. It went away as quickly as it arrived, with no external explanation whatsoever.

      I think it’s fair to draw a spectrum distinction between psychodynamic depression and biological depression (though I’d put “diet-related” on the latter group)

  23. anon says:

    Any chance we can get another post for ADHD? If it’s a ton of work and you’re not already considering it, just ignore this, but if it’s something you’re borderline about and potentially willing to do, then please let this move you over the edge. I have ADHD and depression, but the best psychiatrist I talked to said ADHD is the root cause of my problems and her reasoning made a lot of sense.

    Many people with ADHD report medication helping them. But no medication I’ve yet tried has done anything noticeable. Others report that various lifestyle changes help them out. There’s a lot of information on this, and it would be nice to see your opinion.

    Out of curiosity, does anyone else here have ADHD? Or other mental illnesses?

    • Scott F says:

      Yeah, I have ADHD. My specific path was untreated ADHD bringing about depression, treatment for depression with bupropion, then discovering and treating ADHD.

      The most knowledgeable-on-ADHD doctor I know has explained to me that untreated ADHD tends to cause mood disorders like depression and anxiety, so it seems like you’re on a well-worn path there.

      I can’t offer much in the way of a condensed information post like Scott has done here for depression, but Russell Barkley is well-respected and a leader in the field. If you can watch hour-long youtube videos, this is him talking about management of ADHD, it might contain something new.

      • anon says:

        I’m familiar with Barkley, and grateful to him. His work is excellent, thinking of ADHD as an executive function disorder rather than an attention disorder clarified a lot about my life. But thanks for the recommendation anyway.

    • Scott Alexander says:

      Right now I know very very little about ADHD. If that changes, I’ll write it up.

  24. Lorxus says:

    Wait. Are you telling me that depression is full-on *curable*? Because I had been laboring under the assumption that depression was very treatable but nearly incurable, that even if you did mash it flat for a bit, it’d just come back, and that no matter what you did, you’d be suffering from it to some extent for the rest of your life. I was consequently feeling roughly the same amount of hope for the future as I would if I had any other chronic and possibly fatal disease. Also: how much of this applies to comorbid anxiety?

    • Eli says:

      Some people have outbreaks of depression (this is whence comes the statistic that 1/4 of the population will suffer depression at some point). Some people have lifelong depression. They seem to have somewhat different mechanisms behind them, as to my knowledge the outbreaks are curable, whereas the lifelong is… lifelong.

    • speedwell says:

      There’s always a possibility it might not come back, or it might come back in a milder form, or the spaces between bouts might get longer and longer, or you might learn skills for coping with it so it doesn’t feed on itself and get worse. In my case it feels like weeding a garden; I never quite get to the point where weeds don’t grow, but if I am a good gardener and keep at it, I do eventually get to a sustainable place where pulling the weeds becomes more or less automatic and routine instead of intimidating and overwhelming.

      As for comorbid anxiety… I think that continuing to “weed” the useless anxious thoughts is really effective for me, which is why I used that particular analogy. My therapist taught me to address my “animal mind” directly and say something like, “Thank you for your input, we’ve got this, cancel the alarm”. That is the single best tool I’ve ever learned for stopping that runaway fear-stuff.

      Of course, where depression has an identifiable biological cause that can be addressed (such as hypothyroidism, anemia, etc.), it must be addressed immediately. Cognitive mindwork can help you cope in the meantime, but you have got to address the body issues.

    • Ian Osmond says:

      Depends on the type of depression. Some types are TREATABLE — you can live a non-depressed life, but will be spending the rest of your life doing some sort of maintenance. But, yes, some are actually curable.

    • Scott Alexander says:

      Depression is not “curable” in the sense of “take one thing once and never get it again”.

      As you point out, it is treatable in the sense of something can make you stop feeling the current episode and set you back to normal until the next episode, and if you take it forever, maybe it will stop the next episode too.

  25. James Miller says:

    Neurofeedback is another possible treatment for depression, although it can be expensive and your insurance probably won’t cover it. You should only do it under the care of an expert provider.

    • Andy says:

      I was very very satisfied with neurofeedback treatment for ADHD, and it seemed to have some spillover effects into my Aspergers/ASD symptoms. I just wish it were more widespread.

  26. Kevin says:

    Given that Bupropion has an opposite and more desirable side effect profile than SSRIs (Bupropion is associated with decreased appetite and increased sex drive!), why not just start with the NRI? What I hear most commonly is that SSRIs are also approved to treat anxiety and NRIs aren’t, but this doesn’t seem like it should be an issue with depression without associated anxiety, The more desirable side effects of Bupropion compared to SSRIs seems like a big improvement to quality of life for a lot of people.

    Also, I haven’t tried high doses of oral saffron, but *smoked* saffron is pretty much indistinguishable from really low quality cannabis. I’m skeptical it works to treat depression, but it’s definitely psychoactive.

    • speedwell says:

      You didn’t address me specifically, but before I went to the psychiatrist to whom I was referred, I obsessively researched the medications I thought I might be prescribed, and asked if I might try buproprion. He flatly refused. That’s why I personally didn’t start with it. All the research in the world won’t get you past a determined gatekeeper and may even get you labeled as one of “those” patients.

      • Scott F says:

        I also researched and decided bupropion was a better fit (I seemed to have more of the dopamine- and norepinephrine-related dysfunctions of depression rather than the serotonin-related ones. Whether that is even a coherent hypothesis, let alone correct, is hard to say).

        I was careful about requesting it: I mentioned that I was regularly using nicotine replacement therapies despite never taking up smoking, I found that it helped my depressive symptoms, I described a pattern of NRT usage that fits the description of addiction but said I wouldn’t consider myself addicted, and I reported sexual dysfunction and no major improvements from the first two SSRIs I was put on.

        Nicotine suggests dopamine, stimulant suggests norepinephrine, sexual dysfunction suggests adding bupropion, addiction to nicotine suggests Zyban (bupropion for quitting smoking), all combined it was enough to produce the idea “try bupropion” in my psychiatrist’s head.

        I don’t condone manipulating psychiatrists like that, but bupropion did turn out to be the antidepressant for me.

        • Hainish says:

          Bupropion is linked to an increased risk of suicide attempt, which seems to me why so many prescribers won’t prescribe it alone or as a first measure. (In my experience, it made me a lot more aggravated, even though my depression *seemed* like the type that would respond better to it than to an SSRI.)

    • speedwell says:

      You didn’t address me specifically, but before I went to the psychiatrist to whom I was referred, I obsessively researched the medications I thought I might be prescribed. I asked if I might try buproprion. He flatly refused. That’s why I personally didn’t start with it. All the research in the world won’t get you past a determined gatekeeper and may even get you labeled as one of “those” patients.

    • Creutzer says:

      Bupropion is associated with […] increased sex drive!

      That’s hell of a scary side-effect, though, if you’re not using it only to counteract an SSRI’s side-effect.

      • Anonymous says:

        Why is it so scary?

        • Creutzer says:

          Uhm… How could having a very awkward and impractical desire that is likely to go unfulfilled most of the time strengthened not be scary?

        • Anthony says:

          If you’re not getting any, having a stronger sex drive can make you *even more depressed*. If you have a regular sex partner, especially one who’s complained about your reduced drive, then it’s probably a benefit.

        • ozymandias says:

          I was like “can’t you just wank?” but maybe I’m typical mind fallacying here and other people’s sex drives are not satisfied by masturbation?

        • Creutzer says:

          Anthony is right. It can also make you more depressed if you have a partner who would then complain about your increased drive.

          In my experience, masturbation is a poor substitute for sex and not nearly as satisfying.

        • Ialdabaoth says:

          Especially when what you really want is the physical and emotional intimacy and validation that sex can provide.

        • ozymandias says:

          Ialdabaoth: Yes, but at least IME the desire for intimacy/validation is mostly unaffected by psychiatric drugs. I was on SSRIs that killed my libido, but I still felt the same amount of desire for intimacy/validation, so I assume that something that boosts libido would also leave intimacy/validation desires unchanged. Am I wrong?

        • Ialdabaoth says:

          Not at all, but for me, here’s how it plays out:

          1. Depression kills my libido, does not kill my desire for sexual intimacy.

          2. Attempt to seek sexual intimacy, fail due to “performance issues”.


          4. give up on seeking physical intimacy

          5. Lose partner due to lack of libido

          6. Learn to just not think about it.

          7. Drug brings libido back

          8. Suddenly realize just how much you’ve missed physical intimacy, and find yourself unable to “not think about it” now that libido is back.

          9. DESPAIR

        • F. says:

          To Ialdabaoth:

          “2. Attempt to seek sexual intimacy, fail due to “performance issues”.”

          I hope I’m not being insensitive here, but… here’s something I never really understood about those in your situation: can’t you obtain a feeling of intimacy and prevent your partner from leaving by pleasuring them with oral sex or your fingers or a toy?

        • Ialdabaoth says:

          Not if they explicitly want cock.

          (Forgive the crudeness; not sure how to put this better without losing necessary connotations.)

        • Anonymous says:

          Parent comment anon here. I suppose I failed to recognize that although I experience desire for sex separately from desire for intimacy/emotional connection, others might not.

    • Anonymous says:

      Smoking saffron sound like an incredibly expensive activity.

      • Doug S. says:

        Compared to smoking pot?

        • Ian Osmond says:

          Seems like it would be about the same, actually. A bit of Googling suggests that both are about $2000 a pound.

        • Anonymous says:

          But what’s the active amount? A pound of weed would last me a few months. I don’t know how much saffron I’m going to be smoking.

  27. Jack says:

    Thank you, that was really good.

  28. David Moss says:

    A good source for further info about supplements is the ‘Depression’ section of this psychiatrist’s blog ( She has a particular interest in nutrition. She makes a good case for magnesium and zinc, inter alia.

    Also re. the sleep and light therapy issues: I don’t know if you think it might be worth noting that phase advancement (even cutting sleep short, in the short term), seems to be particularly useful, not just getting more sleep/more light.

  29. Fu's Truly says:

    “A month is totally unheard of.”

    I don’t mean to scare anyone, but I was in a psychiatric hospital for 7 weeks once upon a time. (Later stays were of more reasonable duration.) I was also there against my will, but my will wasn’t very strong at the time, and I was very clearly a danger to myself, so there was no fighting.

    Not that many people will read down this far, but a bit of advice from my limited personal experience and watching some friends go through trouble:
    If you do end up in a psych ward against your will, please please please don’t fight it too hard. IME it will be much more traumatic if you do. You get lots of food, down time to rest, kind-hearted people everywhere who will always sit and listen to anything you have to say and will do everything they can to make you feel comfortable, amazing characters who want to share their bizarre stories with you, etc. Just enjoy it while it lasts. Making it clear to your doctor that you’re not meant to be there is fine, but if you throw fits and try to break out and protest and picket you’re just going to wear out yourself and everyone around you. You’ll usually be there three days if you aren’t meant to be there; if you fight too hard, it can look like you’re dangerous, and they might have to keep you there longer. And if you are kept longer, try to figure out why, and talk calmly about it, and maybe ask to be transferred to a new hospital or a different psychiatrist in the same unit if they’re convinced they haven’t managed to treat you and won’t let you out yet despite your sanity, since someone else might listen better.

    But really being in the psych ward was such a pleasant thing when I was depressed, even when I was there against my will. When I was there on purpose, it was to get my meds switched and get a new doctor (the fastest way IME when your doctor acts out the failure mode Scott described), and everything went by the book. Even in the awful hospital where I stayed for 7 weeks, it was such a relief to not have to face the people I cared about, to not have to go through the motions of preparing for my suicide, to catch up on some reading and learn some math I hadn’t had time for before, to be able to go to someone if someone was violating my boundaries and have that taken care of, etc. It can, in almost all cases IINM, be such a peaceful time if you let it.

    • Ialdabaoth says:

      You get lots of food, down time to rest, kind-hearted people everywhere who will always sit and listen to anything you have to say and will do everything they can to make you feel comfortable, amazing characters who want to share their bizarre stories with you, etc.

      My experience was very different. The hospital had just opened, and as a result about half of the facilities were shut down or severely under-staffed. Inmates were pretty much left to their own devices and allowed to create a sort of pecking order (with the more violent drug withdrawl patients at the top of the hierarchy); the cafeteria would only be open a few days out of the week; the staff were harried and overworked and talking to them at all was a recipe for being given massive doses of tranquilizers. The few of us who were reasonably intelligent and coherent pretty much holed up in one of the spare rooms and formed our own impromptu, unguided group therapy sessions until the orderlies broke us up as a security risk.

      • Fu's Truly says:

        Wow, that’s like horror movie level. >.<

        This reminds me: I ended up in a pretty bad hospital once, nothing nearly as horrifying as that, but certainly way less than optimal. IINM the best way to reduce the risk of ending up in a crappy one is to look up reviews of hospitals in the area and go straight to the ones that looked the best to check yourself in, or to request in the ambulance that you be taken to that one. IME they usually ask for a preference if there are multiple options – and saying "the biggest one" seems to me to be a much better bet than "I don't care" or "whatever's closest", because bigger more often than not means better and more established, and if you can go to a richer part of town you'll probably get better care and and more homey feels.

        Please correct me if I'm wrong about any of this, especially if Ialdabaoth's experience is more common than I think it is.

      • Scott Alexander says:

        That sounds so outside the realm of normal possibility that it might be worth seeing if you could sue the hospital, or possibly talk about your experience with the media.

        • Ialdabaoth says:

          I actually did pursue suing the hospital, as soon as I got out – unfortunately, both the lawyers I talked to said I probably didn’t have a case. One was reasonably sympathetic, and explained that I didn’t have a case because I did have a demonstrable history of mental instability, and that NEVER plays well in front of a judge.

          Three years later, my primary fear is that I can’t give an accurate enough accounting of events to hold up under scrutiny, and I react rather poorly to being accused of making things up.

    • Scott Alexander says:

      I’m very surprised by that. Were you in an acute inpatient facility or some kind of step-down subacute facility? Were you an adult or an under-18? Was this attached to a general hospital, or a standalone place?

      • Fu's Truly says:

        This was at St. Elizabeth’s Medical Center’s ward in Boston. It was for adults and had a capacity of 44. I’m not sure what the jargon in your questions means, but it was pretty standard, and had the same average stay as you quoted above.

        The biggest thing that kept me there, I think, is that they were going to discharge me after two weeks, but then got a new doctor on the unit who wanted to try her luck with me since I had a bit of a reputation, and I told my social worker matter-of-factly that if I’d been let out at that time then I would have done myself in before going to any airport. Also that I wasn’t hiding at all the fact that I was still very suicidal up until the last few days there after I had ECT.

        There was another lady who was there before I arrived and who stayed beyond when I stayed, but she was very badly schizophrenic and had no family to go home to, and I don’t think she had gotten there much before me, and they didn’t seem to expect her to be there for all that much longer.

        Note that if I had wanted to get out, I’m sure I could have played them right – it wouldn’t have been hard for anyone in my position, since they would have been very happy to accept any tiny amounts of evidence that I’d improved after having worked so hard on me. But I didn’t care where I was, and this was easier.

  30. Chamomile Geode says:

    I’ve always wondered whether the idea that “depression was weirdly linked to circadian rhythm and sleep” came from the fact that depression tests weight sleep problems very highly when determining depression (perhaps disproportionately highly)?

    Like, you might have someone who just barely fits the clinical criteria for depression, and one of his problems is insomnia. You fix his sleep, and he no longer fits the clinical criteria for depression, whoo! Except…how many of his other symptoms have been fixed?

    Now imagine a bunch of people like that in a study.

    I do think that sleep problems and depression go together. But they might seem to go together more than they actually do, because the PHQ-9 weights “trouble falling asleep or staying asleep, or sleeping too much” the same as “thoughts that you would be better off dead, or of hurting yourself.”

    • Scott Alexander says:

      I’m working off studies that find treating sleep problems can treat depression.

      • anon1 says:

        The question is, is the test that’s used to evaluate the treatment’s efficacy also heavily sleep-weighted?

        • Chamomile Geode says:

          I’d love to see some kind of study that took the most obvious sleep-question off the PHQ-9 and lowered the depression threshold by a couple of points (making a sort of sleep-blind PHQ-9) and checked the relationship between attaining that new threshold and having sleep problems.

          I’d also love to see a study that took the same sleep-blind PHQ-9 and checked the degree to which patients who had a sleep-improving intervention, improved in other areas.

  31. I’ve got some anecdotes that dark green veggies might be good for depression. Thoughts?

    Also, how much saffron does it seem to take to make a difference? I’m hearing the call of dark green veggies with saffron cream sauce.

    • Ialdabaoth says:

      I know I’ve noticed some improvement after switching to fresh broccoli as my go-to side vegetable.

    • F. says:

      I’m not depressed and have never been, and I’m also just one person so not very meaningful, but…

      The biggest thing that helped me enormously improve my life, has been to drink truly massive amounts of broth from organic greens.

      It’s something I discovered by experimenting with the amounts of greens which I found beneficial to eat. When I increased the amounts, the benefits I noticed from them also increased. However, it got to the point that to further increase the amounts I had to eat so many greens, it was difficult and interfered with my ability to eat other foods. I also noticed that I could get similar benefits if I simply cooked the greens, threw the solid part away, and just drank the resulting broth (or alternatevely use it as cooking water for something that absorbs the cooking water, such as rice) after boiling it down to a small volume to make it more practical (this is important and it’s possible to concentrate a huge volume in a single glass this way). This way, you can comfortably take, in one day, the broth that comes from lots of pounds of greens. The more you take, the more it helps. The devil (or angel) is in the dose.

      For me, the effect is partly immediate but mostly spread in the 48 hours after consumption: a feeling of serene happiness, not a high, but rather a soothing, peaceful optimism. Available energy increases, so does sex drive. Akrasia decreases. Sleep gets better and full of good dreams rather than nightmares. I never noticed a downside to it. Even if I take broth regularly and then suddenly stop, there’s no withdrawal problem, just a return to the baseline. There might be a placebo component to it, but not all of it; I believe I can tell placebo apart from real benefit, just like when you drink a cup of coffee you know that the coffeine rush you feel is mostly real and not a placebo.

      I never suffered from depression, so I don’t know if it would help with that. But if it works with other people the same way it works with me, then it’s something generally helpful.

      These days I always keep a stock of bottles of concentrated (boiled down) broth in the freezer. If i feel down, I drink a couple. They are, if not my antidepressant, at least my anti-feel-down and even anti-akrasia.

      I’ve been advicing a lot of people to at least try this, but I found that people are very resistant to the idea of buying large amount of greens only to “throw them away”. Also, I have no scientific proof of this, just n=1 experience.

      • Douglas Knight says:

        Have you tried non-organic greens?

        This is probably a matter of vitamin deficiency. It might be that changing diets mean that everyone is deficient in the same vitamins, but I think it is more likely that you have a specific mutation that makes it more difficult for you to metabolize the relevant vitamin and it won’t work for other people. Have you convinced any relatives to try it?

        • F. says:

          I switched to organic greens because I noticed they make me feel better than non-organic greens. In fact there are huge differences in the effect depending on how I choose the greens. Not just the magnitude but the details of it. Generic greens may make me feel livelier, but they don’t give me that blissful feeling. And in general there are huge differences in how foods that comes from different sources affect my sex drive. This applies to all foods, not just greens. There’s one guy who grows and sells untreated oranges, those oranges act like an aphrodisiac to me, ordinary ones certainly don’t. That the benefit of greens have many varying variables suggest that it isn’t about a single nutrient.

          Maybe I am deficient in a certain micronutrient and other people aren’t. Then again certain supplements seem to benefit a large amount of people. For instance magnesium and fish oil are popular. So it’s possible that a lot of people can use more of a certain food. And as Nancy Lebovitz wrote there are others out there who think greens are helpful. That’s why I would really like to see if my approach works for others, and I’m disappointed that I haven’t managed to convince anyone who “feels down” to seriously try the green broth thing so I don’t know if it would work.

        • Douglas Knight says:

          Omega-3s are an example of changing diet. People advocate consuming them today because people used to consume them, both because they used to eat different foods and because food that is nominally the same has changed (eg, due to feeding corn to livestock).

      • I’m interested in trying it.

        How does the green broth taste? Does which greens you use make a difference to the effect on you?

        Do you simmer the greens? Boil them?

        • speedwell says:

          I love greens of all sorts, especially when mixed, as many kinds as possible. I would also like to know what specific greens make the “magic broth” 🙂

          Right now the daikon radish is in season in Texas, where I just moved from. They have the most delicious greens ever, especially when paired with snow pea leaves (literally the leaves from the same plant as what they call “mangetout” over here), and mixed in any combination you like with kale, collards, mustard greens, and turnip greens. Cue mouth watering…

        • F. says:

          I’m happy that there are people interested in trying the green broth! In meatspace I hardly ever come across such people.

          Right now I don’t have time to type much but if I have time later today I’ll write another post about the green broth.

          Are you happy with being emailed about this Nancy Lebovitz?

          • I’m fine with being emailed.

            If you want more people willing to experiment, I suggest posting your information about green broth to Less Wrong.

            Also, I’ve been wondering whether vitamins survive that much heat– if they don’t, then maybe minerals are the crucial factor.

      • a person says:

        I can’t try this myself because of reasons, but I wish I could. This is fascinating.

      • Rachael says:

        I’m interested in the green broth.
        Second the request for more details on cooking times etc.
        I’ve just boiled up half a kilo of greens in about 4 litres of water and am now reducing the strained broth down – it seems to take ages

        • I started one last night– no numbers, but I had a large quantity of greens– the bunches looked a lot larger when I got them home than they did at the farmer’s market.

          I’m also at the cooking down stage, which is going very slowly. If I do this again, I’ll chop the greens down small so that it doesn’t take as much water to cover them.

          It’s kale, chard, and scallion tops. The taste is mild but pleasant. I was afraid it would be bitter and/or too oniony, but neither seems to have happened. I’ve done the whole thing at a simmer.

          I wonder how green broth works out compared to dark green veggie smoothies.

        • Rachael says:

          Euugh. Well, I wasn’t expecting it to taste *nice*, but I wasn’t expecting it to taste that bad either. It made me shudder and gag a bit. I managed to get about half a cup down, holding my nose.
          Looking forward to seeing if it has any effect.

        • Rachael says:

          Over here there are things sold as just “greens“, with no more specific ingredient info even in the small print, so I thought F. meant those. (The internet suggests they might be collard greens.) Now I’m thinking I should have made it with some green vegetables that are actually nice to eat, like spinach or maybe kale. I founs the “greens” very bitter; I think I may be a supertaster.

          FTR: I’m not depressed, but I often have low energy levels, and I struggle with akrasia like many people. I found F’s description of the effects of green broth very compelling.

        • My greens came out very pleasant– no perceptible bitterness. I’m probably a sub-supertaster. I don’t like coffee, grapefruit, or beer. I do like chocolate, and can enjoy many dark greens, though mustard greens are too sharp for me.

          I have no problem with just drinking some if I happen to walk past the refrigerator.

          The cooking and reducing was done at a simmer in a big stock pot, and took about 24 hours. The result is a very dark green liquid (looks almost black in jars), but it’s still not obviously thicker than water.

          No obvious effect on mood, but it hasn’t been all that long and I have no idea about dosage.

        • Rachael says:

          I’ll definitely try again with nicer greens.
          Mine was brownish-green and kind of silty – I did rinse the greens, but maybe not enough?!
          I do seem to have more energy today, although obviously it could be placebo or coincidence.

          • Mine has a little grit in the bottom– my greens weren’t perfectly clean, either. I’m not sure what to about that– washing them thoroughly seems like a real pain. Possibly filtering the broth through nylon from pantie hose?

            My greens were bought at a farmer’s market, but then sat in the refrigerator for a week. It’s possible that fresher greens would be better.

        • F. says:

          Wow, a lot of people tried the green broth while I was away! I’m happy that people are trying this.

          So, let’s talk a bit about greens…

          Which greens should you be using? Well, first of all I must mention the type of greens I would never use: Spinach, Collards, and Swiss Chards. Why? Because they have an enormous amount of water soluble oxalate and there are rumors that high regular intake of the stuff might cause kidney stones in certain individuals. I have no idea if it’s true. But for caution, I avoid brothing regularly these greens. Note that on the other hand, it’s perfecly fine to boil these for the reverse purpose: to get rid of the water soluble stuff, which include the harmful oxalates. You can then just eat the solid part, which is still rich in beneficial non-water-soluble nutrients.

          So what greens are left to broth? Whichever ones are available where you live, and grow in the season you’re in. There are a huge amount. In general, if it looks like green leaves, it is what I’m talking about.

          However, it seems from personal experience that plants of the Brassica family are more beneficial to the mood. These (excluding the ones high in oxalates) include arugula, cabbage, kale, broccoli, watercress, bok choi, and many others (you can find more on this on the internet obviously).
          I suggest trying to include some these in your broth, not necessarily as the only component.

          There is not a single green broth; it varies enormously both in taste, and in its effects on mood and energy. It’s very difficult to write a comprehensive guide; I understand that it isn’t a very helpful thing to say but I suggest that you try and experiment with the billions of types of greens that exists.

          However, here’s a very important pointer: The quality of the greens is much more important than the type!

          I wouldn’t expect gigantic benefits from the ordinary supermarket greens, although maybe there are some, especially with Brassica. But supermarket greens are the lowest kind of greens. You can improve on that by trying “organic” greens. However even then there are many differences. Again we’re back to the same advice: youi have to explore and find the greens which you find most beneficial. You can try at farmer’s markets. One guy at the farmer’s market here sells lettuce which he says are “untreated” (whatever that means) and they are GREAT. (Yeah yeah, I know, it could be a placebo, but it doesn’t match my experience because I learned that they were “untreated” well after I had noticed that they were very beneficial). Sometimes I also take trips to a little town where they have volcanic land and ALL the vegetables that they grow over there are particularly beneficial. If you get into greens eventually you’ll discover “secrets” like this.

          In general if greens are full of holes like they have been shot through with a machinegun and have slugs in them, that’s a good sign. Actually the best green are usually backyard grown greens, or the ones that grow in the wilderness, but those are hard to obtain.

          I also advice to very carefully seek and remove any part that is even remotely rotten. With organic vegetables or the ones from small farmers this is frequent and it’s a good idea to cut the bundles in two to see if there is a rotten inside. This is important because even a little bit of rot will spoil a whole pot of broth!
          Another important thing is not to cut your greens much before cooking them. That’s because most vegetabels will oxidize if they are cut. This no longer happens after they are cooked. So the span of time between cutting and cooking must be limited (although it isn’t as bad as fruit). If a part of the greens is already cut, you might consider cutting a bit further to remove the part that was exposed to the air.
          I actually never noticed a difference between the broth of fresh vegetables and that of seven days old ones, as long as they aren’t cut or visibly spoiled.

          Now let’s talk about preparation.

          I’m surprised that Nancy took 24 hours to reduce the broth. She must be doing something wrong. To reduce, I boil at full flame, and after maybe two hours the job is usually done, depending on how much water it was at the beginning.

          Also, Rachel, I would consider half a kilo of greens too little an amount. You see, the point with brothing is to take in amount of greens that would be difficult to eat normally. To me half a kilo doesn’t sound like enough to warrant brothing – half a kilo, you can more simply steam it and eat it.

          Furthermore, if you want to reduce the broth in a reasonable time, you’ll need a higher greens-to-water ratio than 1:8. I suggest at least 1:3. With even more greens/less water than that a considerable part of the broth will remain in the sponge-like leaves. Although more than that can be acceptable, even 1:2. For 4 liters I’d use maybe something like 1.5 kilos of greens.

          Here’s the way I do it regularly: I wash oh maybe 6 kilos of greens and put them in 3 giant pots. (See, you have to think BIG!) One of those pots is really huge and I bought it for this purpose. Then you boil all three simultaneously and then you reduce them.
          When it’s all done, I pour the broth in maybe four 750 cl bottles, and freeze them.
          Then I drink them whenever i feel the need.

          Don’t get me wrong, you don’t absolutely have to do things this big. I don’t always do things this big. When I don’t, it’s a good idea to distribute the reducing among different pots, just to speed it up.

          Regarding washing the greens to remove the dirt… now I really am afraid I’ll be seen as crazy… but when I do those large scale broth sessions, I fill the bathtub and wash my greens in it. I find it time saving.

          Another thing I do quite often, instead of completely reducing the broth to the point it is drinkable, I only somewhat reduce it, and then I use it as cooking water for any dish that keeps or absorbs the water, such as risotto or polenta (sorry that I think in terms of Italian cooking). Usually the result tastes good if the greens are good. You can do a mini green broth every time you cook one of those dishes.

          Regarding whether vitamin and minerals survive the heat – actually besides all minerals, many vitamins do survive the heat. And besides there are other beneficial nutrients beside vitamins and minerals. I’m no nutritionist but my understanding is that there is a plethora of minor and non-essential nutrient not completely understood.

          I considered posting the green thing on Less Wrong, since they seem to be very much into both “lifehacks” and supplements (and open-minded-ness), but I didn’t because I realize that I only have a case study of 1 (myself) and therefore it isn’t a very “rational” thing to follow my advice. I’m also not part of that community.

          Another thing: for me, the biggest and most telling proof that green broth is working as desired is the improvement in dreams. The other benefits might go unnoticed because of other factors that affect my day, but there is very typically an improvement in the dreams; nightmares get rarer and anyhow less ugly whereas soothing, wonderful dreams become frequent. Another thing is that I’m much less likely to have episodes of antisocial crankiness. And better energy, and more optimism. But the dream thing is the surest sign.

          Good luck with everyone’s experiments with greens!

          • I simmered my greens in a big stock pot rather than boiling them– I thought I’d be a little gentle with them since I didn’t know whether you used boiling or simmering. Since I now have some evidence that boiling is good enough, I’ll try that on the next batch.

            This batch had chard– future batches won’t.

            I don’t think there’s a problem with you posting to Less Wrong– all you need to do is say you have a sample of one. It’s a fairly cheap and probably safe experiment, and if it improves mood that much for a fair proportion of people, I’d say it’s worth trying. I have 19K karma with 92% positive, so I’m pretty sure I understand the culture, especially for non-technical posts. You’d want to put it in Discussion, or possibly in the Open Thread that’s posted weekly in Discussion.

        • F. says:

          I have to point out one downside of Brassica family vegetables: while they seem to be more beneficial to your mood, they also seem to have a special power to make you smell. And stink up your place while your cooking them. When I was eating and drinking more cabbage I was sometimes told that I smelled like cabbage. I don’t consider the smell of cabbage to be offensive, but a lot of people do. I’ve repeatedly been told “what is this stink coming from your kitchen?” These days I’m not consuming a lot of Brassica any longer (albeit not for the reasons above).

        • I ran into a non-obvious failure mode– I froze the two mason jars, and both of them broke.

          It turns out that even though the broth thoroughly cooled down, you should only freeze food in straight-sided jars. Jars with shoulders inhibit the expansion from ice enough to get broken.

        • anon1 says:

          Wide-mouth pint mason jars don’t have shoulders. Filling a larger mason jar only halfway is also likely to work.

        • Rachael says:

          F: Thanks for the detailed instructions!

          Half a kilo *is* too much to eat as far as I’m concerned, especially of the tough fibrous collard greens. I guess that means I’m not eating enough greens in the first place.

          I used as much water as I did because they needed that much to cover them.

          I tried it again this evening with broccoli. That was much more palatable. I also have some pak choi to try. I think the problem with my collards was that they were still dirty. The broth looked like a muddy puddle and I didn’t realise it wasn’t supposed to.

        • F. says:

          To Rachel: you don’t need to submerge your greens completely in water as long as you put a lid on the pot. The greens will deflate and end up completely in the water. Even if they don’t end up fully submerged, if there is a lid the steam will slowly cook the part exposed to the air and cause it to release the juices inside.

          The ideal proportion of greens to water (in making broth through boiling) depend on which is your limiting factor, greens or (room for) water. If you had infinite amounts of greens, the ideal proportion would be 1:1.

  32. No one special says:

    On today’s episode of “It’s the economy, stupid,” I want to point out that Celexa (citalopram) is on the $5 drug list at wal-mart. So even if you don’t have prescription insurance, you can probably afford to get this drug. Now, affording the doctor’s appointment to get the prescription, I dunno. But if you tell your doctor that you don’t have health insurance, they’ll be more likely to write you larger prescriptions. I went to a psychiatrist after I lost my job, but before I lost my insurance, and he was like, “I’m going to write you a prescription for 40mg, twice a day, but I want you to take 20mg once a day, so that should last you for 4 months on a single bottle.”

  33. Alli says:

    I don’t agree with antidepressants as a good first step. You can have SUCH TERRIBLE SIDE EFFECTS. And if the first kind you try doesn’t work, getting off of it can still be unbearable, and trying other things can just end up being a repeat of that process.…/emotional_health/depression_01.htm I found some incredibly helpful information here. There are a million things (ok, not a million – several) that have been shown in studies to work as well as antidepressants. They are things like exercise, meditation, cuddly pets, and light therapy. CBT works better than drugs. And then there are supplements to correct some underlying causes of depression. Fish oil, magnesium….

    In my case antidepressants worked very well, but had terrible side effects, and when I stopped taking them I was much much worse than before. So I did a bunch of research, and then I adopted two kittens, prioritized dancing a lot and going outside a lot, really did some research into what supplements were needed and started taking those, adjusted my diet – it took a little bit of time and a lot of effort to prioritize taking care of myself, but after a few weeks I was feeling great again.

  34. blacktrance says:

    I don’t know the details, but I have a friend who had depression, and the first thing his psychiatrist prescribed to him made it much worse, to the point of serious suicidal ideation. He was later prescribed something else instead, and that helped him. I wish I knew more details about what he was prescribed first, but maybe somebody knows something about this anyway.

    • Fu's Truly says:

      Isn’t it common for SSRIs to increase risk of suicidal ideation in the first week or two, or is that just for adolescents?

      • anon says:

        I remember hearing something about this. The mechanism was that if you have severe depression you’re paralyzed and won’t kill yourself, but if you get better then you’re capable of killing yourself. Seems like that would apply to adults as well as adolescents.

        • Douglas Knight says:

          That sounds like an explanation of suicide from SSRI, not of suicidal ideation.

        • Kat says:

          Another potential reason is that one of the roots of depression is actually too much seretonin, this is still a hotly debated theory however. SSRIs work by flooding the neurotransmitters further to desensitize them, but this can explain why many psychiatrists notice that patients get worse for a couple of weeks after taking medication but then get better after that.

    • Hainish says:

      Was it bupropion (Wellbutrin)? The same thing happened to a friend on this drug.

  35. Ian Osmond says:

    A couple things I’ve noticed: I’m a layperson, but one who’s really, really interested in this stuff:

    First: I’m coming to believe that depression isn’t so much a specific disease as a category of conditions which all present in similar ways, but which have different root causes, and therefore different treatments. You can’t treat anemia, bipolar II, or Hashimoto’s thyroiditis with SSRIs very effectively.

    But — second: for many forms of depression, any intervention will have some level of temporary positive effect. I mean, down to putting crystals on someone’s chakra points and chanting at them. Since much of how depression presents is through the depressed person’s perceptions and thought-processes, and the placebo effect is especially effective on perceptions, literally ANYTHING is likely to have a mild, temporary benefit, which will taper off until the person is back to their baseline depression, but doesn’t realize it, since depression can be insidious. This makes finding effective treatments extra-difficult.

    Third: there are at least three different categories of depression, which we can call “neurochemical”, “situational”, and “cognitive”. And there are lots of different kinds of depression under each type.

    Fourth: you can have more than one type of depression at once — and probably do. Neurochemical depression will train you to have depressed thoughts, and also fuck up your life so that it’s actually depressing. Depressed thought processes will fuck up your brain chemistry over time, and fuck up your life. And a fucked-up life will give you plenty of reasons to think in a depressed manner, which will mess with your brain chemistry. So treating depression on multiple axes at once can be beneficial.

    The plus side of that interconnection is that working on fixing any of those three areas will have benefit for the other two, as well. While each area can mess up the other two, each can also help the other two.

    Fifth: it could be that depression is at least partially like shock or autoimmune disorders — a useful mechanism which has sometimes gone rogue and become pathological. If everything in your life DOES go traumatically wrong, it makes sense to shut down your emotions for a while, like a circuit breaker, to give you a bit of time to process without feeling. It could be that depression is that mechanism going overtime.

    Sixth: depression really is that serious. In the First World, in areas where we’ve been able to control most parasite-borne diseases and diseases you can vaccinate against, it is a strong contender for the disease we’ve got that causes the most morbidity and mortality, and the most loss of human potential. To be sure, it only holds that crown in places where we’ve controlled malaria, cholera, smallpox, and so forth — but, where I live, when I live, it’s the biggie.

  36. Anonymous says:

    Minor correction: moclobemide is misspelled as “mobeclomide”

  37. Pingback: Link blog: new-orleans, psychology, game-of-thrones, music | Name and Nature

  38. Nesh Selvar says:

    This posts takes a more conservative and less speculative approach then I’ve come to enjoy in this blog. You don’t mention either serotonin releasing agents, or long duration triple re-uptake inhibitors which, while not part of current psychiatric practice, have some very promising initial studies, along with being predicted as effective by most of the current theory on neurotransmitter effects. While you list a number of different type of supplements and the possibility of ECT, this still seems pretty mainstream. My personal opinion after looking in to how neurotransmitters work in relation to mood I’ve had the suspicion that that just throwing nearly random combinations of direct mono-amine agonists, say chosen for a chemical supplier stock list (after applying a basic filter for safety and duration), would have a higher efficacy that most modern pharmacotherapy.

    • Anonymous says:

      Someone — I believe it was Scott in a previous post — mentioned that it is striking how depression seems to be treated by such diverse meds, and often by meds that work in completely opposite manners. They posited that any change in the brain state can “knock” one out of depression.

        • Anonymous says:

          I’m thinking of exactly that!

        • Anonymous says:

          That’s exactly what I was thinking of.

          Wow, I even “remembered” that there was a heart analogy, although I didn’t put it in my original post, and the one I thought of was different. I was thinking of saying this was similar to how coughing can stop heart palpitations, because it disrupts the palpitation, causing the heart to start beating properly again.

  39. George says:

    Any thoughts on testosterone supplementation? I’ve read that low testosterone can cause depression and vice versa…

  40. Everyone everywhere agrees SSRIs are much better than nothing.

    Well they would agree on that, otherwise they would be out business.

    Mental diseases are particularly likely to respond to the placebo effect. The more dramatic the treatment, the more effective the placebo. I bet you would get much better results if you sacrificed a bull to the gods and poured the blood over the patient, while dressed like a cartoon mad scientist.

    Electroshock works, because it has the same rituals as surgery. Give them surgery rituals, but actually cut them a bit while they are still conscious, but, due to the influence of muscle relaxants, helpless. Then draw out the evil spirits through the holes. I bet that would be way more effective than electroshock, and, unlike electroshock, would not give them brain damage.

    Serious depression is often cured by the sufferer taking a humbler role in life, requiring more obedience and less decision making, which role he can perform more successfully, and getting approval and acceptance in this lesser role Or perhaps taking a humbler role is what causes depression, and success at this humbler role cures it.

    • Ialdabaoth says:

      I’m sorry, I can’t hear you over the dog-whistle.

      Which is frustrating, because I feel like you’re actually saying something relevant right now.

    • Ialdabaoth says:

      Following up after some thought:

      In my Darker moments, I tend to think along these same lines. I would frame it a bit differently though:

      Some people are innately (one might say Ordained) to be successful and powerful in life, and others are innately suited for slavery and inferiority. Still others aren’t even *that* useful.

      Modern culture poisons us with the lie that everyone has inherent worth, and that everyone can succeed if they just try hard enough, and that everyone deserves a chance.

      Depression is God’s way of saying “really? Fuck you. Someone will be along to collect you shortly.”

      In a proper society – one with slavery and concentration camps and conscription to war and death marches and human sacrifice – depression would never be allowed to take hold, because the Lebensunwertes Leben would never get the chance to feel sorry for ourselves.

      • As you say, in your darker moments– there are quite capable high-status people who suffer from depression, and it’s not as though Nature is all that competent.

        • Ialdabaoth says:

          there are quite capable high-status people who suffer from depression, and it’s not as though Nature is all that competent.

          Which DOES happen to refute James’ theory – unfortunately, when I find myself believing in it, logical refutation and counter-examples aren’t exactly relevant. It really is an excellent just-so story for reaffirming your belief in a Just World.

        • Depression is the too-hard-basket. If someone shows up the doctor who cannot walk, and the doctor cannot see any reason why he cannot walk, he is deemed to be depressed. It is the category “other” on the list of ailments.

          So no treatment is likely to be effective on all, no description will cover all. But status role too high covers quite a lot of them.

        • Ialdabaoth says:

          THIS oughta be good.

        • ozymandias says:

          …Do you have evidence that patients who can’t walk and have no reason to not be able to walk are deemed depressed as opposed to, say, somatoform disorder, which is specifically defined to mean “physical ailments caused by psychological trouble”? I mean, certainly some people with chronic pain or fatigue issues are misdiagnosed as depressed, but those seem a lot less objective than “can’t walk.”

        • Do you have evidence that patients who can’t walk and have no reason to not be able to walk are deemed depressed as opposed to, say, somatoform disorder, which is specifically defined to mean “physical ailments caused by psychological trouble”?

          My wife was diagnosed as depressed by multiple doctors, even though her symptoms were cognitive impairment and difficulty and slowness in making voluntary movements. They wanted to give her electroshock, even though it seemed glaringly obvious that there was nothing much in common with other patients diagnosed as depressed.

          This provoked me to research the matter, and it became obvious that people diagnosed as depressed often had remarkably little in common.

          The “typical” depressed person is someone who needs to humbly perform a lower status role. The rest are a random grab bag with little in common with each other.

      • Sarah says:

        A less exaggerated version of this claim is credible. Depression-like behavior may be an adaptive response to losing social status, at least in the ancestral environment. Being more subdued and inhibited is a good way to avoid being a target. We do know that serotonin levels are lower in low-status monkeys.

        It doesn’t mean that in a modern civilization we really need to organize things along primate hierarchies. A “dominant-subordinate” relationship between rhesus monkeys looks a hell of a lot like an abusive relationship between humans.

        • Julian Simon who cured his own depression by inventing something like cognitive therapy, believed that depression was caused by making negative self-comparisons, and feeling helpless to change.

          One approach (of many– he’s thorough about the possibilities) is to lower one’s standards.

          I’m still not seeing evidence that humbly accepting a lower status is especially good for depression.

          And I can believe that depression is used as a diagnosis when doctors don’t know what’s wrong, but I’m not sure it’s even the most common mistake of that kind. “It’s all in your head” is quite a favorite.

        • Ialdabaoth says:

          Being more subdued and inhibited is a good way to avoid being a target.

          It’s also a good way to survive being a perpetual target, when actively trying to resist would cause lethal escalation.

          A “dominant-subordinate” relationship between rhesus monkeys looks a hell of a lot like an abusive relationship between humans.

          As a former abuse victim, one man’s “abusive relationship” is another’s “business as usual” and a third’s “he’s getting what he deserves”.

    • a person says:

      Serious depression is often cured by the sufferer taking a humbler role in life, requiring more obedience and less decision making, which role he can perform more successfully, and getting approval and acceptance in this lesser role Or perhaps taking a humbler role is what causes depression, and success at this humbler role cures it.

      Do you have a source, or any evidence, anecdotal or otherwise for this? I am not sure where you are getting “often” from, and I am interested in knowing if there is any validity to this claim.

      • Andy says:

        Second the call for evidence. Scott, is there anything in the medical literature about the effect James describes?

  41. Kat says:

    Be wary of the kinds of fish you eat for pollutants, like farmed salmon, albacore tuna, and shark. Wild Alaskan Salmon is expensive, in high demand, and often counterfeited using farmed salmon. Sardines are great and lots of Omega-3s, also anchovies, trout, and mussels. Mercury can even make your depression worse.

    Medication is important. One of the worst things about depression is that it damages your hippocampus, which is important for memory. Reduced memory function further frustrates you and sinks you deeper in depression. Medication has been shown to stop or even reverse this. Most medications focus on seretonin, but norepenephrine and dopamine dysfunctions are also shown to play a role. From my experience with SSRIs, weight gain can be a serious issue and should be dealt with as soon as you notice your weight increasing otherwise it’s hard to go back but it can be done.

  42. Kaj Sotala says:

    You seem to be saying that electric shocks are the closest thing that we have to a miracle cure for depression, that the experience of receiving them isn’t unpleasant, and that we’re not aware of any major side effects aside from minor memory loss. If all of that is true, how come they’re a last-resort thing rather than one of the first things to do?

    • Scott Alexander says:

      1. Public grossed-out-ness. I dunno about Finland, but in America there is *extreme* antipathy to ECT because it was used in very abusive ways in mental hospitals in the past (ie without anaesthetic, to “punish” troublemakers, this probably happened a lot more in movies than in real life, but still a little in real life) and now everyone is suspicious.

      2. Side effects. You do lose memory, sometimes quite a lot, and longer-term side effects are still under debate.

      3. Cost and difficulty. You’ve got to go to the hospital, get anaesthestized, and get hooked up to a complicated machine. Usually a course of treatment takes several appointments a week for several weeks. That’s very expensive and inconvenient compared to taking a pill every morning.

  43. Shenpen says:

    Six months? Alex, is it possible for a person to be _forever_ depressed from teenagerhood into mid thirties?

    To be honest I think to a large extent the question of depression may be cultural: for example Americans are expected to be happy. Everybody is expected to walk around with a big smile and answer “How are you?” questions as “Great!” Americans expect work to be interesting, challenging and fulfilling, marriage to be sexually satisfying etc. when it does not work that way it gets diagnosed as depression.

    But a culture can be very different. I am Hungarian. If I would ask people “how are you?” which I don’t I would half expect them to reply “go fuck yourself”. Everybody is grumpy and we don’t consider it depression, we consider it normal. For example we do not expect work to be interesting. We work because we must, and at best we expect it not to suck much.

    At any rate, I don’f it maybe I was depressed all my life – or at least by American cultural standards. I never really had much enjoyment in life and never really expected or care about it. Best times were those where there was no negative pain or problem, therefore just the usual problem of boredom. I don’t think I have ever did things because I expected them to be pleasurable. I do things because I must do them in order to avoid pain. I never expected or wanted to be happy, I expected my life to oscillate between having to cope with problems, and having no problems and thus being bored. Pursuing pleasure looks like luxury thing to me – don’t the hedonists have other things to do, like making sure nothing will go wrong?

    I don’t know if it is a forever depression. In American culture perhaps in mine not.

  44. Scott says:

    Just a reemphasis that if you want to start taking new drugs then you should do quite a bit more research than just reading this post. Find out what the side effects are and how common they may be, what dosage you should take based on weight/age/sex/etc, different drug interactions, and of course any legal issues (if you need to get security clearance, for example, always get a prescription). Start off slow, and take note of effects. Modafinil, for example, made me slightly manic, and it wasn’t really obvious until I looked back on it.

  45. Hedonic Treader says:

    Thank you for this useful post, Scott Alexander.

    That said, there is a differnece between “a danger to oneself” and “a danger to others”. One violates the Schelling point of nonviolence, whereas the other doesnt.

    Additionally, what some people consider harm, others consider not harm. I do not think voluntary painless death is always a harm, but can sometimes be a real benefit, e.g. to prevent agony and suffering.

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  47. Fifey says:

    “Okay but has some really questionable parts. Like how he neglects to mention anything about movement disorders with neuroleptics (a serious concern even with atypicals) right before the paragraph where he calls the cheese effect “life-threatening” (when tyramine alone rarely leads to hypertensive crises and certainly not the foods he listed unless by cheese he meant aged blue-veined) Ew. Better off just forgetting everything written about specific medications in that.”

  48. Kimberly says:

    Thanks for an informative post! Love your sense of humour 🙂