When you use words like "bi-polar and depression" it gives the sense that this is a medical disease. And while speaking strictly, it is indeed a medical disease -- I want people to see the raw human factor in this.
Depression, for example, in my experience, and from what I've seen -- often has a cause; a rational, explainable cause (that the sufferer often isn't aware of). When you treat someone's depression as a "medical disease" like the cold or the flu, you are completely ignoring the human factor.
I don't know why people ignore the real human factor when it comes to depression. Instead they resort to a bunch of drugs that do not address the root (psychological) cause of the depression, but rather just give some temporary fleeting relief.
This is a very different illness to depression. And depression has different forms.
Yes, talking therapies are powerful. But you seem to be making the mistake that a talking therapy isn't affecting brain chemistry, or that drugs are inherently bad.
Comments like yours are very frustrating. Do you talk about people ignoring the real human factor when we put a broken bone in a cast?
Talking therapies do not stop these kinds of mood swings, but they may be able to help people cope with the effects of mood swings. As importantly, they can help people follow their prescription, failure to do so being the #1 reason for these pharamceutical treatments to fail.
But the biological theory of mental illnesses is very far from established. We have no reliable way of identifying them and no understanding of their mechanism. Existing studies of the medications we use to treat them have been subjected to pretty devastating critique; e.g. the most comprehensive review of the SSRI studies (by Irving Kirsch et. al.) found no clinical significance beyond placebo for the vast majority of patients.
The belief that mental illness is biological ("chemical imbalance in the brain" and so on) is very widespread and very emphatic. But the gap between that and what we actually know is drastic. What explains that gap? Most likely, it's that (a) people very much want to believe it, and (b) the belief has been heavily marketed.
Your comment is far more nuanced. You're reading the science. While I gently disagree with you I understand what you're saying, and I could fairly easily be persuaded that you're right.
The comment I replied to had some worrying flags.
It made blanket statements about meds; it suggested that depression has a "root cause". I took that to be a reference to classical psychotherapy -- some event happened a long time in the patient's past and that event must be uncovered by the therapist for the patient to address it and recover. Re-reading the post I see that I might be wrong! Perhaps the post is just talking about regular evidence based cognitive model.
> The belief that mental illness is biological
Well, for something like bipolar disorder this feels like it's true. I don't know much about BPD, and I don't know many people in real life who have it. But it seems that people need the meds.
When talking about depression I recognise that there are various types. I'm not a doctor and have no special knowledge. When people ask I suggest they investigate talking therapies (and probably CBT) first. But I know that people might get benefit from meds, especially if they're on the more severe end. I know that meds can have unpleasant side effects.
It's great when someone replies as thoughtfully as this, and I love your phrase "gently disagree". Would that more disagreements were of this kind.
> Well, for something like bipolar disorder this feels like it's true.
I agree. The open question is on what level these things are best to be understood. In some sense everything about us is biology, just as in some sense everything is physics. But we don't think of, say, heart disease as best addressed by physics. Similarly, that there is a biological stratum to our actions and feelings does not automatically mean that chronic emotional suffering is best understood as biology. One might as well conclude from the tongue and larynx that language is biology too. And indeed it is, sort of—yet its meaning lies elsewhere. Or you might as well conclude from the importance of neurons to learning that education is brain biology. Why bother with teachers or schools? We should just 'learn' the neurons directly. Such examples are obviously silly, at least given our current knowledge.
To know that chronic emotional suffering is a biological disorder requires more than the involvement of biological phenomena in it; it requires an experimentally verified model. My understanding is that we don't have anything close to that. The one that entered the public imagination, the serotonin-deficiency theory, is widely dismissed by experts [1,2,3,4]. The only argument seems to be whether they knew it was false from the beginning or discovered that it was false decades ago.
Yet we insist that modern science has discovered that mental illness is biological just the way that cancer is and so on. What do you call a conclusion like that which goes far beyond what we actually know?
It's worth realizing that psychiatry has always made this claim. The grounds for it shift every 20 years or so, and the previous grounds are always dismissed as ludicrous if not harmful (think lobotomies etc.). Nevertheless we're perpetually certain that we're beyond all that now.
> But I know that people might get benefit from meds
I don't think anyone questions that; the question is whether the benefit is that of a placebo or not. My understanding is that SSRIs are no more effective a treatment for depression than tricyclics were a generation earlier; their advantage is rather that they have fewer side effects [5]. So whatever explanation there is for their efficacy must plausibly explain how both of those (presumably very different?) biochemical mechanisms could do it. Given that even inert placebos produce most of the same effect (Kirsch's finding), the placebo explanation is pretty clearly a major candidate. If there's another, I'd like to know about it.
(I realize you were talking primarily about bipolar disorder, but I haven't read about that, so I've continued to talk about depression instead. That may lessen the relevance of the above.)
One of the problems with describing an illness as psychological is that people think we are dismissing their illness, that we are saying the illness is not real. They think we are either saying that it's all in their heads, or that it's not serious, or that it's just a matter of them needing to "pull their socks up".
I think that might be why people cling to a biological model for mental health problems.
Obviously, we're not saying any of that. I say that there are powerful talking therapies; that these are evidence based and effective for many people; that medication may help although it's probably over-prescribed and it can have unpleasant side-effects; and that some people won't respond to any of that and may need electro-convulsive therapy or other severe interventions.
I agree that people tend to overstate the biological model, and that is a problem. It's a problem because, as you say, we don't know if it's true, and it's a problem because it steers people away from talking therapies.
Mental illnesses like cancer are defined by there effects not there underlying cause. As such they tend to treat a wide range of physical causes under the same general umbrella. And drugs or therapies which work wonders for some people often have little benifit for others. However, there are well studdied physical mechanisms for things like specific types of addiction which do present a physical mechanism.
A great example of this is Heroin addiction and alcohol addiction are vary different biochemically. There is even a wide range of Alcholhol addictions, but you will see them treated side by side. The simple truth is we can't really understand why someone has issues but we do have treatments that help people lead productive lives and that's enough to be useful. Just as your dentist does not need to know how pain killers work to use them effectively.
Steven Novella addresses the biological theory of mental illness quite well in this 10 minute segment from the podcast The Skeptics Guide to the Universe: http://www.youtube.com/watch?v=-MLdvKzLl6k
i realise it's anecdote, but i grew up with a parent that was depressive. was on lithium, etc. life was pretty damn miserable until the first SSRIs became available - they were the first drugs that had any noticeable effect and they changed our lives.
> the most comprehensive review of the SSRI studies (by Irving Kirsch et. al.) found no clinical significance beyond placebo for the vast majority of patients.
No. Biological theories of mental health and mental illness are very much established.
And yours is a complete mischaracterization of the work of Kirsch et al.
Their meta-analysis found that in ALL cases of depression, there is statistically significant improvement in quantitative measures of depression treated with SSRI. In moderate to severe cases of depression, the improvement was clinically significant (ie a clinician and patient clearly note the improvement). The meta-analysis done on clinical trials were overwhelmingly trials of 6 weeks of SSRI or less. Suicidal patients are almost all excluded from such trials. Treatment groups were treated with SSRIs via research protocols, and not usual clinical practice: there were no attempts made to match patients to an SSRI that would be most likely to help, to wait on a response, to use SSRIs that were helpful based on a family history; dose adjustments were typically prescribed by study protocol and not by patient response, patients were not switched to another SSRI when there was no response or if intolerable side effects developed, often no attempt to treat side effects with other agents were done, etc. In other words, none of the things any physician routinely does to optimize treatment were done in those trials, and yet there were STILL improvements in measures of depression across the board.
No reputable psychiatrist or physician will fail to recommend an SSRI in cases of moderate to severe depression. Therapy can also be helpful, but the evidence is overwhelming that SSRIs help in clinically significant ways in moderate to severe depression. There is no credible doubt about it.
Despite your assertions about what "people very much want to believe" - in my experience, people very much want to believe that the brain is somehow different - that something beyond biology is at work. Believing that somehow depressed or otherwise mentally ill people can just "snap out of it" or "pull themselves up by their bootstraps" is erroneous, unhelpful, but fits nicely into really completely shitty and cruel narratives about human beings.
But please. Perhaps you'd like to advance a theory on how an organ like the brain differs from every other organ and does its work in ways not explainable by biology, chemistry, physics, etc.
And yours is a complete mischaracterization of the work of Kirsch et al.
It isn't my characterization so much as a paraphrase of various sources I've read/heard on this, including Kirsch himself. My understanding is that Kirsch and Sapirstein's findings are two: (a) for all but severe depression, the improvement of SSRIs over placebo is measurable but too small to be clinically significant; (b) even that small measurable difference is questionable, because the studies were not really double-blind. (Patients could figure out which group they were in because of the SSRIs' side effects.) Is either of those descriptions of their findings wrong?
I haven't kept a list of sources, but one I remember is [1]. Is Kirsch mischaracterizing his own work?
I noticed that you didn't use the word 'placebo' in what you wrote. My understanding is that Kirsch et. al.'s findings were specifically about lack of clinical significance beyond placebo. Could that explain the discrepancy between your description and mine?
Perhaps you'd like to advance a theory
I would not. Do you think that lack of a better theory has anything to do with whether this one is substantiated or not?
Shouldn't the default position be "we don't know"?
No that's a common misunderstanding. Science is the search for the best model/theory as such it's hard to rank something as better or worse than we don't know. Thus the default theory is "There is no relationship between X and Y". Even if not clinically useful there does appear to be a connection and as such you can replace the default theory.
After even more research the current theory is something like. "They appear to beat placebo's which have no side effects." Which again is far more useful than "We don't know." As it suggests comparing them to placebos that have side effects. Again not because they are going to help you treat patents directly, but because it tells you more about the disease and possible what research could be useful.
Science is the search for the best theory as such it's hard to rank something as better or worse than we don't know. Thus the default theory is "There is no relationship between X and Y".
For the purposes of this discussion, that's a distinction without a difference. (BTW I edited my comment before your reply showed up, and had deleted the bit you quoted.)
More significantly, your suggestion of comparing SSRIs to placebos with side effects strikes me as an excellent idea; it is what Kirsch's study would naturally seem to suggest. I wonder if such studies will ever be undertaken.
The more conservative estimates from the present analysis found that differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos. Further research into unblinding is warranted.
Bipolar disorder cannot be solved with therapy. Additionally, clinical depression is different from situational depression. Yes, you are right, that many people would benefit from therapy in addition to drugs, but bipolar disorder, especially, is not a disease that responds to it. It is a chemical/biological disorder and needs to be treated as such.
The many many people in our lives suffering from a chemical/medical issue can not solve their problems with therapy alone. Depression is multi-factored and definitely partly chemical - maybe for some it's solved by spending more time in the sun but for many of our friends it is a serious clinical issue not to be mistaken as having a purely talk-it-out solution. Stephen is an excellent example here: he has the sheer intellect and forwardness of self-examination to know it can't be beat without looking at all factors and wouldn't presume to say that it's solved with drugs, or therapy, alone.
And in these cases the situation can be exasperated by well meaning friends, relatives and practitioners searching for a root cause that, if addressed, will make it all go away.
Jesus christ, yes. This is why many people suffering from mental illness don't talk about their problems: they end up feeling worse because their friends either try to "fix" them, or they end up comforting the friend, or both. It's always with the best of intentions, but I recently had an experience where I truly understood how terminal cancer patients feel; a friend wanted so badly to help, and kept feeling worse and worse about what was going on with me, and I just tried my best to comfort them at my own expense.
When the only reason you haven't killed yourself is that you don't have the strength to do so, the last thing you want to do is have the people you love going down with you.
(Note, before people get worried: I'm on the way up again now, and getting the help I need to ensure I don't get bad again.)
If I was one of your friends, would you have liked me to have just treated you as I normally do? If I had someone close who was dying, when I'm seeing them I think I'd just interact with them as I normally do (though accepting and recognising they are, in fact, dying), and not let the fact that they were dying to get in the way of our relationship. I rationalize this by thinking people don't want to feel being pitied upon. They want to feel important; and seeing them just because I want to see them would help in that regard.
Yes. Absolutely, absolutely, yes. What I want more than anything else: to feel normal. Even if it's just for 10 minutes while we're bitching about how bad some new album is, or playing a game. I won't say that's universal, but in my case I can't imagine anything better.
For me this depends very much on who it is that's trying to help.
If they've not experienced something similar to the mental health problems I'm suffering from it's usually best if they treat me as normal. The effort required to try and explain aspects of what I'm going through, usually with little success, is often far more detrimental than any benefit they could hope to provide. Being distracted from the problems, even if only for a short while, can be blissful and hugely appreciated.
On the other hand, I'm usually happy to be treated differently by people that have had similar experiences to me. I can often communicate to them in a sentence things which would take hours of conversation with somebody who'd not been there before.
It's a difficult situation for both the supporter and the supported, particularly in the early days.
> The effort required to try and explain aspects of what I'm going through, usually with little success, is often far more detrimental than any benefit they could hope to provide. Being distracted from the problems, even if only for a short while, can be blissful and hugely appreciated.
> On the other hand, I'm usually happy to be treated differently by people that have had similar experiences to me. I can often communicate to them in a sentence things which would take hours of conversation with somebody who'd not been there before.
I very much agree with both parts of what you've said here. I'm curious if & how you tend to balance between the two?
Generally when I'm having a bad time just having some casual distraction works fine, especially from someone who doesn't know what's wrong.
When I'm stuck in a rut, just having a few friends who can stop me bullshitting and keep me talking works wonders.
Most people I regularly spend time with are aware that I'm bipolar even if they aren't in the "been there" category. This is quite deliberate. When I'm well, I do my best to explain the difficulties I have during an episode to try and avoid people feeling alienated. This is not something I can do effectively whilst ill.
The result of this seems to be that when I become unwell people in this group provide me with the best kind of support that they're equipped to give while others help me talk it out.
Unfortunately this hasn't been so easy to achieve with family members as it has with friends since they're so desperate to see me well, although things are improving. Fortunately (or unfortunately) my wife is also bipolar so I don't have that problem with her.
As to balancing talking it out vs. distraction? I rapid cycle so distraction can be very effective for dealing with short-term mood swings. If I notice that I'm distracting myself a lot then that's a sign that bigger trouble is just around the corner and is when I start to seek help. My wife and I discuss the state of our mental health very frequently so there's always a certain amount of discussion going on as well.
I always cringe when I hear or read a non-depressed person's advice to a depressed person. It often involves getting more exercise and going out in the sun. Getting more exercise and sunlight might help this person, but it probably won't be enough. The person will probably need cognitive-behavioral therapy and maybe even medication. Even then, a depression-free life is not guaranteed. Mental illness is complicated.
In case you hadn't seen it, the author of Hyperbole and a Half recently posted about her depression, and she hit on similar things in a poignant way: http://hyperboleandahalf.blogspot.com/
>maybe for some it's solved by spending more time in the sun but for many of our friends it is a serious clinical issue
Or so a 21st century corrupt medical establishment, that abuses and neglects science in favour of greed (from inventing mental issues out of thin air to over-prescribing medication, to even advocating unnecessary operations) likes to tell people.
Depression sure is a true medical condition for some (relatively few) people -- but in the quantities and degrees it affects the general population though, it's anything but.
Please stop spreading misinformation. There are many kinds of depression, and there are two significant camps - little-d depression, which is depressed mood from negative life events (missing the bus up to funerals) and big-d Depression, which has biological elements and is what people mean by 'clinical depression'.
Temporary relief may be what is needed under many circumstances. I'm personally quite clear on the roots of my depression, but that doesn't make it easier to cope with. For some people it's a mystery or problem that once solved, ceases to be debilitating. For others it's an endocrine problem, best treated with drugs. For yet others, it is best treated with cognitive exercise. Each case is different and dismissing a whole class of clinical strategies is no better than treating those strategies as a panacea.
Are anti-depressants over prescribed? Sure. Are there cases where the root cause of depression is biochemical? Yes.
I've been on meds for bipolar for five years, and I see a therapist every week. The meds get me stable - like healing a broken broken leg - and the therapy is my personal trainer building me up to run the marathon. Neither would be as effective without the other, but in my case, if I could only have one, it'd be the meds.
mental illness is an illness where something has gone wrong with the body in the same way that cancer is an illness where something has gone wrong with the body. Stigmatizing it in any way is not useful. Telling people to "just be happy!" isn't useful.
"Depression, for example, in my experience, and from what I've seen..."
Your anecdotal observations shouldn't drive your understanding. Go read up on it. Suffering from mental illness myself I find your post quite offensive.
I roughly agree with your sentiment, but your last sentence is IMO a bit too rough with the "resort to a bunch of drugs" part.
Any psychiatrist worth his salt, will primarly prescribe drugs as a means to help people cope, while working on the actual underlying causes. Indeed, in many cases, using drugs in the treatment may be the only option to make the patient's day-to-day life bearable. Drugs may also be essential for allowing the treatment team to examine, possibly very problematic, underlying issues.
Also, a SSRI, for instance, can of course not "treat" someone of a clinical depression; you will virtually always need professional cause-oriented therapy to get better. Most patients know this, or will realize it as they experience how their meds work.
Finally, there are some mental disorders, and many individual cases, that require constant medication, despite of the quality of the other treatment given. For example, full-fleged bi-polar disorder, where a manic or a depressive episode may have very severe consequences.
I have read that book and it is indeed very good because it gives the reader tools to succeed and the clinical research proving that what we think and the way we think greatly influences our mood.
Dr. Burns stated that the methods often work best when used in conjunction with medication. Some people may be so far down the rabbit hole that medication is necessary to restore improper brain chemistry.
Even in cases that can/should be solved by addressing a root problem, often you still want to apply drugs so that the patient doesn't, for example, kill himself in a down period between his/her second and third psychotherapy session.
Pills are easy... Aside from a 30 minute visit to the doc.
Addressing the root cause typically requires working with others over a period of time... and that work is oftentimes what people with depression want to avoid.
what is ignored (thanks to psychiatry being left wing, and trying to mitigate the downside rather than build on the upside) is that bipolar brings a lot of BENEFITS. when bipolar people are very hyper, they can achieve great things.
thats the reason why people with bipolar usually don't want to be medicated - the highs bring genius.. the problem are the lows which follow it.
This doesn't sound like you're talking from personal experience.
Saying that the highs bring genius is a gross simplification.
Yes, manic episodes can provide productivity boosts and huge amounts of energy but it doesn't have to go much further before it becomes impossible to complete a thought let alone a sentence, where you cannot sit still, where your judgement is severely impaired or you're suffering psychoses.
None of these symptoms (and there are many more) are particularly conducive to productive work, let alone breakthroughs.
(PhysOrg.com) -- The Greek philosopher Aristotle once said "there is no great genius without a mixture of madness," and now there is some scientific evidence that there is a link between mania and high IQ and creativity, since a study of over 700,000 subjects showed those who scored the highest grades were almost four times more likely to develop bipolar disorder in their adult lives than those scoring average grades.
It's not like that, at all. Depressed or overly happy, I'm not productive, I just lose time doing nothing usefull, nor correct... But while stable, I van achieve very nice stuff pretty fast, because I van use my obsessive side tout good end. Trust me, being high or low is as destructive as the other, for you, your project and the people around you.
In bipolar disorder, depressive episodes are much more common than manic episodes. They get high , but they suffer much more than they gain from their illness and AFAIK, bipolar depression is much worse than usual unipolar depression and much much worse than depression caused by life events.
I'm not aware of any conclusive research showing that depression is more common than mania although people are more likely to seek treatment when depressed than when they're manic.
I also struggle to believe that there is any evidence to support your claim that depression as experienced by somebody who is bipolar is worse than somebody who is unipolar which is again worse than depression caused by life events.
Depression, for example, in my experience, and from what I've seen -- often has a cause; a rational, explainable cause (that the sufferer often isn't aware of). When you treat someone's depression as a "medical disease" like the cold or the flu, you are completely ignoring the human factor.
Many cases of depression can actually be solved without drugs -- by addressing the problem at the root of it. "Feeling Good: The New Mood Therapy" by David D. Burns, goes into this. (http://www.amazon.com/Feeling-Good-New-Mood-Therapy/dp/03808...)
I don't know why people ignore the real human factor when it comes to depression. Instead they resort to a bunch of drugs that do not address the root (psychological) cause of the depression, but rather just give some temporary fleeting relief.