Best books on depression?

[Ego]

Not a book but a massive new study:
https://www.nature.com/articles/s41380-022-01661-0

The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations. Some evidence was consistent with the possibility that long-term antidepressant use reduces serotonin concentration.

This from the Guardian Article

“Many people take antidepressants because they have been led to believe their depression has a biochemical cause, but this new research suggests this belief is not grounded in evidence,” said the study’s lead author, Joanna Moncrieff, a professor of psychiatry at University College London and consultant psychiatrist at North East London NHS foundation trust.

“It is always difficult to prove a negative, but I think we can safely say that after a vast amount of research conducted over several decades, there is no convincing evidence that depression is caused by serotonin abnormalities, particularly by lower levels or reduced activity of serotonin.

The UK media seems to be doing a good job of covering it. Strangely, US media has virtually ignored it. I wonder the reason for the disparity.

[theanimal]

Hmm, makes you wonder. The fact that pharmaceutical companies are over 70% of ad revenue for US media companies probably has nothing to do with it.

[zbigi]

I always suspected that the (mild) effect of antidepressants on depression is way more complex that just "fixing serotonin". Anecdotally, people who've taken then have said that it made them emotionally numb and flat - they stopped feeling despair, but they also stopped feels many other things. Sounds just like drinking to me.

[ertyu]

to me, depression isn't a disease, it's a symptom. I also don't think depression is one thing with a single cause. For some, fixing their diet and exercise is enough because the cause of the depression was the body being gunked up from an unhealthy lifestyle. For others where the depression is caused by adverse life events or dysfunctional beliefs, therapy might be best. For still others, medication might be needed. I remember reading that approximately a third of the people belong to each group.

I would be very hesitant to dismiss medication and compare it to drinking because even if drinking gets you emotionally numb, too, it also has a multitude of other negative side effects on life. On the most basic level, if you drink, you will probably not feel very motivated to hit the gym, eat healthy, stay off other bad habits (cigarettes, cocaine, etc) because alcohol lowers inhibitions. Alcohol is also bad for the body, in any amount (people can choose to take on this risk in exchange for "fun," but that doesn't mean the risk isn't there and that the same person wouldn't have been healthier if they didn't drink). Last but not least, for people whose depression includes suicidal ideation, medication can be life saving.

@zbigi: dismissing medication as you have could discourage a depressed person from seeking life-saving help. Depressed people already believe there is no point and things can never get better. What you have written is thoughtless and irresponsible. For a depressed person, the answer is not, "get over yourself and just get drunk." Anyone depressed, please take your depression seriously follow treatment validated by research.

Source: a non-suicidal, anxious, depressed fuck who didn't benefit from drinking in the slightest

[chenda]

What you have written is thoughtless and irresponsible. For a depressed person, the answer is not, "get over yourself and just get drunk."

@Zbigi didn't say that, I think what he wrote was quite reasonable. My own experience on SSRIs was like that, mind numbing with other side effects. They are essentially psychotropic drugs which alters the way the brain functions. They don't restore a biochemical shortage. That's not to say they are all bad, the effects may be beneficial for someone depressed and, as you say, probably do save lives. But I hope we develop better ways to treat depression in the future.

[ertyu]

Alright: "sounds just like drinking to me" sounds like "might as well just get dunk" to me. Which I still maintain is thoughtless and irresponsible.

[zbigi]

Alright: "sounds just like drinking to me" sounds like "might as well just get dunk" to me. Which I still maintain is thoughtless and irresponsible.

"Sounds like drinking" means that they affect people in similar way, not that they're equivalent and one is a 100% substitute for the other. Negative side effects of alcohol usage are widely known.
What I wanted to emphasise is that SSRIs are not "cure for depression", but merely something that masks the symptoms, to a degree [1], for some people, for some time (their efect can wean off). It's a hell of a way to make billions and billions off depressed people's insurance, but in terms of actual help they're more of a crappy bandaid at best - which is not to say they should be dismissed off-hand, in many cases a crappy band-aid is still better than nothing.

[1] Their efficiency is so marginal that drug companies had to send them through clinical trials multiples times until they finally got a result that counted as statistically significant.

[AnalyticalEngine]

I am not a doctor, but from my personal experience and research, what we call depression is really two different things. The problem is that depression can be both a root syndrome (Major Depressive Disorder) and a symptom for another, different disorder. You can also have co-morbid psychiatric conditions, so coming up with an accurate diagnosis and treatment for a personal case may take a lot of trail and error.

SSRIs tend to be the front line psych medication for a lot of mood disorders because they have relatively low side effects compared to more hardcore psych drugs (anti-psychotics, etc). But they really only work if you have MDD as the root issue. If you have a personality disorder, a trauma disorder, bad lifestyle, etc, you will still be experiencing depression but SSRIs are not as effective. The only way for clinician to really know this is to put you on SSRIs and see if they work. Unfortunately, this can trap someone in a cycle of going on and for them for years, trying to find the right dose, when really they have PTSD and need a different treatment.

An unfortunate attribute about the healthcare system is that you need to advocate for yourself. Doctors are just people and can end up unaware of the latest research/just put you on whatever worked for someone else. Unfortunately, if you have depression, advocating for yourself is incredibly difficult because you barely have the energy to take a shower. SSRIs are meant to close the gap between therapy/lifestyle by giving you just enough energy that you can advocate for yourself/figure out what is causing the depression.

My anecdotal, personal experience was that neither doctors nor therapists nor SSRIs could really understand what the cause of my issue was and I had to take my life into my own hands. I ended up reading a lot of books written for therapists and implementing the techniques myself. Combined with a fix in diet and exercise, as well as teaching myself to take my emotions seriously again[*] instead of gaslighting myself, I was able to make major gains on my depression without professional help. However, this is incredibly hard to do, and I was really only capable of getting here due to exceedingly personal reasons that are probably not replicable.

[*] As I've mentioned in my journal, Plotkin's method is what worked for me.

[chenda]

@analyticalengineer - 100% agree.

[Ego]

The fact that pharmaceutical companies are over 70% of ad revenue for US media companies probably has nothing to do with it.

Amazing that it has been three days since the release of the study and the supposed paper of record still has not acknowledged it.

The thing I find most remarkable is how effectively these companies silenced/alienated/marginalized researchers and regular people who realized this forty years ago and spoke out. So many careers and reputations ruined.

What I wanted to emphasise is that SSRIs are not "cure for depression", but merely something that masks the symptoms, to a degree [1], for some people, for some time (their efect can wean off). It's a hell of a way to make billions and billions off depressed people's insurance

[1] Their efficiency is so marginal that drug companies had to send them through clinical trials multiples times until they finally got a result that counted as statistically significant.

Playbook:

1) Sell it as a cure even though experts know it is not a cure and are concerned about side-effects.
2) Silence/alienate/marginalize experts who express concerns and reward those who remain silent.
3) When it becomes obvious to everyone that it is not a cure and has terrible side-effects, create new versions that are "better".
4) Shift the damaging meds to liability limiting subsidiaries or even better get immunity from liability.
5) Create medications to "cure" the damage caused by the side-effects.
6) Goto 1).

Sound familiar?

[Lemon]

Interesting paper - Need to read it in full

But the thing is SSRIs work accept maybe they don't or, at least not as much as we would like.

As people have said, generally pretty well tolerated medication but the difficulty with a lot of mental health is getting the diagnosis right and availability of other treatment options. Complex social issues etc. also make things hard.

There is also a big difference between being sad and being depressed. Again between moderate and severe depression. But culturally that is...problematic.

[theanimal]

@Lemon- I'm confused by your statement as the second study you linked to disputes the methodology of the first study and thinks their conclusions are unproven. Specifically:

Several methodological limitations in the evidence base of antidepressants were either unrecognised or underestimated in the systematic review by Cipriani et al.
...
The evidence does not support definitive conclusions regarding the benefits of antidepressants for depression in adults. It is unclear whether antidepressants are more efficacious than placebo.

The Nature study that just came out that @Ego linked addresses that concluding statement, therefore doing what the first Lancet study purported to do but this time with more methodological rigor. So as the Nature study illustrates, it would appear that SSRIs do not work for curing depression.

[Ego]

....generally pretty well tolerated medication but ...

I agree that the medical establishment (by way of pharma) generally considers them well tolerated. Add this to the list of things I find remarkable.

-abnormal heart rhythm
-stomach bleed
-seizures, sweating, and tremors from serotonin syndrome
-suicidal thoughts
-weight gain
-diarrhea

[mooretrees]

I’ve witnessed the benefits of SSRIs for two loved ones. I have witnessed only benefits when the right medication was prescribed . A lot of drugs have side effects, the list can be quite scary at times, but in reality side effects can be very minimal.

I’m hesitant to say they are totally useless if some people gain their life back after taking them. For one person, they helped tremendously and perhaps most significantly, helped this person sleep normally for the first time in their adult life. Maybe their depression was due to a lack of sleep and nothing to do with serotonin. But the SSRI helped. I really appreciated @Analytical’s thoughtful post.

I agree they are tremendously overprescribed, but I know people who have done everything to avoid them and still benefitted from them. I’m grateful they exist. I’m also grateful that new research suggests ketamine infusion therapy and therapeutic mushrooms can help people who are treatment resistant.

I hope there is compassion for those struggling with depression from you @ego, but I am only reading judgment from your posts. Am I wrong?

[Lemon]

@animal really good questions

But the Nature study does not show SSRIs don't work. It is looking at the umbrella theory of serotonin as a cause of depression. It is not making claims about treatment options.

The 2 papers I linked come to different conclusions. This is pretty normal in medicine because (terrifyingly) the published research evidence is just not there (past 36 weeks of treatment nothing for SSRIs as they point out). This absence of evidence however doesn't mean something doesn't work. After all there are no randomised control trials proving the efficacy of parachutes. So I wouldn't be swayed just from the more recent paper that there is definitely no benefit to SSRIs when 1) I have treat people with them and see benefit and 2) Huge numbers of other people have been treated with them and observationally also had benefit. Should someone do a large methodologically sound RCT? Obviously! But that costs money, most of the commonly used antidepressents are off patent (so no drugs company is going to fund it) but we would certainly benefit from it. It could be a total revelation if it came up truly null effect (or show us how much of a positive it really is). This sort of scenario is unfortunately common in medicine.

Does that mean pills should be thrown at everyone who says 'I am depressed'? Clearly not and that is why people need to see a doctor and you can't just go and buy Prozac with your M&Ms.

@Ego Yup still well tolerated. Pretty much all pills will have those sorts of side effects or worse listed on the bottle. Most are rare and much less than other medications e.g. Antipsychotics listed earlier. As always a risk/benefit that someone needs to talk with their Doctor about before starting.


Therapy etc. Can also have negative outcomes and also goes through cycles of what is seen as 'best therapy' as the research tends to get done by people in academic institutions who believe in 'insert therapy type here' they tend to be biased but also really good as a department at delivering the therapy as intended which overestimates effect size when more general therapists start using it. Again, this doesn't mean therapy doesn't work (it does), but the evidence base is far from perfect with the added issues of sham pills for an RCT are easy, sham therapy is more tricky.

[Ego]

I hope there is compassion for those struggling with depression from you @ego, but I am only reading judgment from your posts. Am I wrong?

You are not wrong. There is judgement. And condescension. And disgust. And a definite lack of compassion for the industry that has done these things to people.

I have no doubt that people experienced improvements after taking and SSRI. The placebo effect is strong and real. As someone mentioned above, the drug companies had to move their trials to Bangalore because the placebo response is so strong in the US where we've been trained like Pavolv's dog to produce the desired result when given a pill.

A pretty girl will believe herself to be ugly if repeatedly told so by a respected authority. A smart guy will become an idiot and the world's-best athlete will come in last in a race if they are made to believe something that isn't true.

For decades the default response of whitecoats to depression was to treat for chemical imbalance. They did so at the prodding of the companies that hold the patents to the holy-grail of meds, those that must be taken every day, forever.

For more than a decade now whitecoats have told people their dementia is caused by amyloid plaques and the drugs to treat them were so expensive that they threatened to bankrupt Medicare. Another bombshell report out this past week in Science shows that the research was (likely) fabricated.

https://www.science.org/content/article ... rs-disease

And, of course, the ongoing crusade to vaccinate everyone every three months when the very experts in charge of the process knew..... well.... watch for yourself.

https://twitter.com/TexasLindzay/status ... 8329913344

[Qazwer]

Not a comment on SSRI usefulness - that is a complicated interesting literature which is beyond my ability to explain in a few words

But the article stating that serotonin is not causative in depression states nothing about the usefulness of SSRIs in treating depression. Assuming equivalence of causation and treatment is a logical fallacy.
The best explanation of that which I have seen is the following thought experiment. No one believes that headaches are caused by a lack of Tylenol yet Tylenol helps headaches.
The potential chemical cause of depression is interesting from a future research perspective but the amount of people stating that it is important from a treatment perspective has been overblown IMO.

The possibly most famous drug discovery in history was penicillin but it was used for many decades before its mechanism of action was elucidated. Alexander Fleming just knew it killed bacteria.

[Bonde]

In medical school depression was not a difficult subject. Today when I talk to my colleagues about depression we agree that it is a difficult diagnosis. In itself the diagnosis is a quite simple syndrome of x symptoms for y amount of time. But when you talk to persons presenting depression-like symptoms it is often difficult to make sure that it is a depression and thus
- is global (affects all parts of life)
- has no major fluctuations in the past weeks (many hours or days of feeling happy/normal)
- the quality of the feeling is depressed (feelings are difficult to describe)
- low reactivity (e.g. low energy after to much work, more often burnout than depression).
Then you also have to distinguish depression from other mental disorders e.g. anxiety disorders.

You can find the ICD-10 green book (research criteria) and blue book (clinical) for diagnosis of mental disorders on google for free. It is a bit heavy reading but then you go straight to the source of the clarification. ICD-10 is used in most of the world. The US uses the DSM-5 made by the APA which is similar but costs a lot of money. The library should have a copy.

Concerning SSRI the consensus is that they work. Not a wonder drug but it helps many people with depression (and anxiety). The biological source(s) of depression has not been fully established but placebo and randomized clinical trials testing SSRIs on 1000s of participants have found clinical effect. Much like e.g. migraine that is also not fully understood but some drugs have been found to have clinical effect. A minority of professionals argues that SSRIs don't work or side affects are worse than the antidepressant effect.
The major problem is that many people take it as the only treatment because it is cheap and convenient. Guidelines recommend a more holistic approach including some form of psychotherapy. See e.g. NICE guideline from the UK for depression that recommends SSRI (not always for less severe depressions) and other treatments:
https://www.guidelines.co.uk/mental-hea ... 26.article

Books
CBT you can try out alone as the therapist more or less follows a manual that you can find online. A good place to start could be the Beck Institute. I have heard good things about them but I'm not specialized in CBT: https://beckinstitute.org/cbt-resources ... dividuals/

I work with the psychoanalytic/psychodynamic approach.
irvin Yalom has written great novels for layman about the approach e.g. "Lying on the couch".
Glen Gabbard's "Psychodynamic psychiatry in clinical practice" (any edition will do) was for me the best intro to theory and clincal work. He gives a brief intro to ego psychology, object relations theory, self psychology and attachment theory, and then covers treatment of all major disorders.
Bruce Fink's "Fundamentals of Psychoanalytic Technique: A Lacanian Approach for Practitioners" was fpr me the best intro to lacanian psychoanalysis. The book describes how Lacan developed Freud's understanding of the unconsciuos and added linguistic theory.
Both books have many examples and short patient notes/vignettes. I think that the books can give some insight to layman, esspecially on how our past intereferes with the present and that many processes are unconscious. But I'm not sure that it will create as much change doing it yourself compared to CBT that is much more tangible and only concerns conscious problems.

[ertyu]

Brief solution-focused therapy is another therapy style that's done by-the-manual. I taught myself it off of youtube - I fell into a hole one day and it was a while ago, but I took copious notes on what questions are asked and in what order.

EMDR is also formulaic, and both manuals of various protocols and example sessions are available - the books of protocols as pdfs, the sessions on youtube. you have to be able to withstand what will come up, however. EMDR is intense and evryone and their mom will advise against EMDR-ing yourself not in the presence of a professional. I don't have trauma stong enough to give me flashbacks but i was still rolling on the floor barely breathing with how hard i was crying. my own fault, tho, my approach to these things is, when you're going through hell, keep going, even though the nice lady that wrote the pop psychology book said to ground into your happy place and go there when shit gets intense. try at your own risk etcetera.

[ertyu]

Glen Gabbard's "Psychodynamic psychiatry in clinical practice"

Reading this now (I found the 5th edition) and I'm still at the beginning, but I very much appreciated the discussion of how the degree of one's response to anything - e.g. whether one develops depression or ptsd etc in reaction to stress or a traumatic event - is linked both to inborn, structural differences in people's brains and to any subsequent changes to the brain due to environmental influences at key stages of a person's life. Way too often these are taken to be issues of morality, e.g. people who respond with depression, ptsd, etc. are seen by many to be weak and deficient as human beings. This is then often internalized. The discussion in this book helps with being compassionate both for oneself and for others who struggle.

Thank you for the book recs, bonde, and for a sane response post to the discussion in this forum.