n=21, no control group, zero blinding. Placebo response is notoriously high in depression studies, so it's unacceptable that they didn't include a control group.
This technique is a variant of rTMS, which has been around for a long time. We've had years of positive rTMS study results that failed to replicate in real-world conditions. There's some early evidence that it might do something positive, but it's not clear that it's a viable treatment option. In most major cities you can usually find at least one obscure rTMS clinic somewhere, but they won't offer the exact rTMS technique studied here. They also won't give you 50 sessions across 5 days as used in this study.
It's very disappointing, even suspicious, that they didn't include a control group. It's trivially easy to include a sham rTMS treatment because the patients can't see the magnetic field. At minimum, they could have split the group into low-dose and high-dose to demonstrate a dose-response relationship. Yet they deliberately chose to avoid any control group or dose-response measurements.
I can't access the full text, so I don't know when they measured the patients' depressive symptoms. If they scored the depression inventory on the final day of the 5-day treatment, this wouldn't be very promising as a long-term treatment. The real test would be how the depression remission holds up after the rTMS treatment is discontinued. If the remission persists for months, that would be truly impressive. On the other hand, if this only works with 50 in-office rTMS sessions per week, it's not a practical outpatient treatment.
I would love to be wrong and for this to be the holy grail of depression treatment, but given the circumstances I think it's best interpreted as an outlier study unless/until someone else reproduces it. I don't think we'll all be going in for 50 sessions of rTMS across 5 days any time soon.
Is everyone ignoring the part in the article saying they're now doing a controlled study?
> The researchers are conducting a larger, double-blinded trial in which half the participants are receiving fake treatment. The researchers are optimistic the second trial will prove to be similarly effective in treating people whose condition hasn’t improved with medication, talk therapy or other forms of electromagnetic stimulation.
> n=21, no control group, zero blinding. Placebo response is notoriously high in depression studies, so it's unacceptable that they didn't include a control group.
Went into the comments to find out about this, this is ridiculous, there have been numerous studies on precisely that, take for a popular example Vsauce’s Power of suggestion video (soooorry, not sure if its free now for non-red subscribers, but valuable anyway) https://youtu.be/QDCcuCHOIyY
> How do papers like this get published? This is a conference paper at best.
The why is obvious: It's #1 on Hacker News right now, and spreading like a wildfire across my social media. People love to hear about promising new depression treatments, because we all know someone who suffers from depression.
Strangely, most rTMS papers follow similar patterns: No control groups, small sample sizes, questionable methodology.
The methodological issues would have been trivially easy to correct from the start, so I assume the omission of control groups is intentional. I think it's geared toward generating publicity and drumming up grant money. The core rTMS technique seems to do something for depression, so it would be great if someone could translate that into a practical, sustainable treatment.
Treating `depression` or claiming to have cured depression is something a lot of people look forward to. Couple that with the fact that we are all sitting in the midst of an ongoing pandemic, news stories with catchy titles like these are bound to attract extra eyeballs.
It’s a feasibility study. As the paper says, since the results are so promising, they are following up with a more statistically rigorous (I.e. expensive) study. I think it’s great to communicate ongoing developments and promising research tracks to other scientists. That’s completely different from sensationalized media reports, which is the real problem here.
A colleague of mine pointed out it's important to look at the conflicts of interest and funding sources. One of the patients seems to be from a family funding the study, and some of the authors have filed patents on the protocol.
... without randomization or controls to randomize to.
Either this will win the Nobel Prize, or it won't hold up. (Guess which one is more likely.)
A few reasons I don't think it will hold up:
- this is a university press release
- N = 21
- no control group
- no blinding
- university press release doesn't even claim it's a new approach, just incremental improvement on an existing approach
- the paper (link below) is about evaluating safety, feasibility, and "preliminary efficacy" (i.e., they're not advertising this as a robust result)
>With SAINT, study participants underwent 10 sessions per day of 10-minute treatments, with 50-minute breaks in between. After a day of therapy, Lehman’s mood score indicated she was no longer depressed; it took up to five days for other participants. On average, three days of the therapy were enough for participants to have relief from depression.
One imagines that three to five 10 hour (!) days of a presumably highly-trained professional spending time and attention and focus on a patient serves as no less than an incredibly strong placebo. It would be interesting to see a blinded study where the transducer functionality was replaced by a small heater (or whatever is needed to make the system act, feel and sound the same for all involved).
It would be lovely if this held up. Depression and other psychological issues are insidious.
OTOH, getting that much attention for depression seems quite rare, and given that there are strong learned behavioral issues with depression that require a lot of retraining, that means high frequency intervention is needed.
Talking to a therapist 1 hour a week doesn't help you manage those waves of depression you feel 20x a day 6 other days of the week. If you are going to change any subconscious or neurological patterns, you need to intervene in those moments of symptoms.
How scalable could this possibly be to widespread depression? Critical depression already can lead to intensive hospitalization with frequent daily intervention, so something seems off.
Either that preexisting intervention also would have a big success rate, in which case this isn’t news and just isn’t applicable widely due to scale, or else this effect is not due to frequent attention / intervention.
How does fake treatment work in a clinical therapy test setting?
I'd think I'd either figure out that the person giving me therapy was talking nonsense pretty quickly, or their 'placebo' therapy is indistinguishable from actual therapy, in which case am I still a control?
Yeah but there was an article posted a few days ago about how Reiki can't possibly work but it still does.
IMO the only way to blind this is to put people in an automated machine that either turns the magnet on or it doesn't (and it makes some noises either way). You can't have highly trained professionals in the loop making people feel valuable by giving them all this attention, as that could be a confounding effect in both the alleged-treatment and the alleged-placebo.
> IMO the only way to blind this is to put people in an automated machine that either turns the magnet on or it doesn't (and it makes some noises either way). You can't have highly trained professionals in the loop making people feel valuable by giving them all this attention, as that could be a confounding effect in both the alleged-treatment and the alleged-placebo.
It's fine as long as both the experimental group and the control group get the same amount of attention, right? If both groups show the same amount of improvement, that means it was caused entirely by the attention, not by the magnetic treatment.
msandford is saying that you can only run an experiment like this and get good results if the treatment is administered entirely by a machine. PhasmaFelis is saying that as long as both groups get similar amounts of professional attention then you can still get good results. I'm saying that to make sure you get equal levels of professional attention you need to blind the professionals to whether the machine is enabled.
(I agree that this is what the "double" in "double blind" means, but that's not what we were talking about.)
You do everything the same except don't turn on the machine. This isn't talk therapy, they're just sitting there in a chair with the device held to their heads.
To contest one point only: A strong placebo effect that lasts is quite valuable, and should not be undervalued when it comes to depression. If this ends up being a way to consciously strengthen the placebo effect to successfully treat patients, there's a lot of people who'd benefit.
It should still be distinguished from non-placebo effects where possible and I agree with all of the concerns and worry expressed in this thread.
This is not true at all. If you have three groups, an experimental, placebo group, and control group and you find strong durable lasting effects in the placebo group that's still a placebo effect.
> Those with the high-COMT variant had the weakest placebo responses, and those with the opposite variant had the strongest. These effects were compounded by the amount of interaction each patient got: For instance, low-COMT, high-interaction patients fared best of all, but the low-COMT subjects who were placed in the no-treatment group did worse than the other genotypes in that group
> Analyzing the data amassed during the first 10 years of the study, Hall found that the women with the low-COMT gene variant had significantly higher rates of heart disease than women with the high-COMT variant, and that the risk was reduced for those low-COMT women who received the active treatments but not in those given placebos. Among high-COMT people, the results were the inverse: Women taking placebos had the lowest rates of disease; people in the treatment arms had an increased risk.
Re:placebo, these were people with treatment-resistant depression. They've had depression for many years, have undergone many rounds of medication and talk therapy (I've been through 7 drugs including ketamine, and 3 therapists). This is not a group that is prone to placebo improvements, they're cynical and hopeless, though of course a double-blind study is still needed.
It means you don't have to buy the expensive magnet. You just get people to hang out with a patient for a couple of days and they'll respond better than 10x the average response of an SSRI.
To get a feel for the impact, an SSRI makes you an inch taller, the placebo effect makes you another inch taller. And this intervention would make you 10 inches taller.
>With SAINT, study participants underwent 10 sessions per day of 10-minute treatments, with 50-minute breaks in between. After a day of therapy, Lehman’s mood score indicated she was no longer depressed;
Maybe she was lonely and all that time with technician was enough to help her perk up :)
As someone who is in therapy for quite some time and read quite a lot about psychology, I can please take any claims of "evidence"-based short-term therapy approach with gain of salt. Particularly, if it's a very short term manualized approach of therapy eg, CBT style therapy.
Lots of research in CBT is plagued with abuse of statistics, manipulation of randomized controlled trials, sensalization, and over-hype. For the vast majority of time CBT is good for symptomp reduction and patients relapse frequently. Frankly, the depressed people I know in real life, I don't know how many of them would be benefitted by CBT style therapy.
My own experience is it took me almost a year of therapy, reading psychology and philosophy, lots of self-relfection and going to dark places in my mind to see marked improvement in my depression. If you are suffering from depression, please give psychotherapy a try. It'd be hard, but it's worth it!
I very much agree, we have to be cautious with our optimism.
Concerning the approach, this study looked into a fairly new form of rTMS, namely iTBS. Here is paper detailing how it differs from 10Hz rTMS, with a specific focus on potential cost savings: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6742475/
We certainly need more data on iTBS effectiveness and I hope that a properly controlled, double-blind study can yield some information on whether this is actually effective on a larger scale and in the long term. A sample size of 21 is simply to small to make any judgement on that.
I'm more hopeful. The remission rate probably won't hold up in subsequent studies, but the current remission rate is enormous. I think there is a very good chance that some effect holds up.
Also I don't think your analysis that it's all or nothing, i.e. that it has a true effect size of "Nobel prize winning" or nothing is true. I think it's very likely that there is some effect size it's just not world changing.
> I think there is a very good chance that some effect holds up.
Huge RCTs with many thousands of subjects only sometimes find effects for SSRIs which are the first thing doctors prescribe for depression after telling you to go get some exercise and sleep better. This study has N=21, isn't an RCT, and isn't even claiming to be studying efficacy. In terms of result robustness, this is about as strong as posting a poll in your team Slack channel.
Anyway, the study wasn't even focused on efficacy! It says so in the paper. But that didn't stop Stanford PR from putting the supposed efficacy in the headline anyway to get clicks/shares.
> Huge RCTs with many thousands of subjects only sometimes find effects for SSRIs.
This has everything to do with small effect size for SSRIs and nothing to do with this study. Doctor's prescribe SSRI's not because they are especially effective but because they are especially safe. For example MAOI's have much higher effect sizes than SSRI's. Also I'm pretty sure every single RCTs with thousands of subjects regarding SSRI efficacy has found an effect, just not always a large one, but I'd love to see a study as a counter example.
But on this to this study
What do you think a control group remission rate would be 20%, with ECT it's 48%. They had a remission rate of 90%. An effect that size is most likely a true effect or outright fraud. What is the probability this happened by accident? My probability is rusty but that seems like that would be highly unlikely. It's gotta be less than 1/1000.
If you gave a pill you thought might help people lose weight to 21 people and 90% of them last 80 lbs. Would you think "hey there's no control group", or "holy shit I probably found something".
If the entire effect were guaranteed to be attributable to the magnet intervention with 48% as the baseline likelihood of remission, the p value is ~0.0003.
That's just math.
The question is how believable it is that the entire effect is attributable to the magnet intervention.
Exciting research results announced in university press releases turn about to be something cool infrequently to put it mildly (also true for small studies, also true for medical results, also true for self-reported studies, etc), so my prior is that most or all of the effect will go away.
I've seen lots of studies come and go but I don't remember any which demonstrated as dramatic a change as this one.
This study showed a 30 point improvement on the MADRS, that's from 35 -> 5. That's insane, the typical anti-depressant move a patient 3 points.
What happened? 21 people got this technique applied to them, and 19 of them achieved remission. The average person in this study went from severely depressed to not depressed in 5 days. I'm a big fan of Gelman and the garden of forking paths, but you can't fork your way to a result like that.
Something interesting happened here, even if it's not the therapy.
Transcranial Magnetic Stimulation has had poor results in the past, failing to live up to its previous hype. So I want to know what they did that's fundamentally different from past results. If what they did differently was do a poor job in their experimental setup, then that is enough to explain it.
I'm not a scientist, but I'm curious if any of you know: why do these important studies use such small N? I think its pretty obvious that a small N is not statistically significant, yet for this study, or the myriad of COVID-19 studies, the N is usually < 20.
It's just so frustrating that professional scientists just completely ignore this statistical fact. Why not use use N >= 100 or not at all. It just confuses things in my opinion.
You issue is with people upvoting things into HN frontpage, not with N.
There are multiple reasons why small N is not bad thing.
Firstly, multi year research projects are not silent for years or decades before they deliver final paper. They publish interim research, technical reports, exploratory research or preliminary research to clarify issues and fine tune the direction of research. You do something and you publish it.
Secondly, multiple studies where N is small can be more reliable than one big study with large N. There are errors other than statistical errors.
Thirdly. Effect size is much more important than N. N=1 can win you a Nobel price if the effect size is big enough. Grow a mice that weights 10 kg and N being 1 or very small number is good enough. There are many studies where N is tens of thousands (p < 0.001) but the effect size is so small that the result is not scientifically interesting.
Finally, statistics is not the final arbiter of importance of the study. It has become standard to add it into every publication, no matter how small. But researchers don't focus on that.
---
Everyone wants to participate in the discussion and most people in comment sections know something about statistics but little to nothing about the subject, so you always get the 'correlation is not causation', 'small N' so it's irrelevant talking points.
Generally because bigger N means the study is more complicated logistically ( cost, finding participants, whatever). And if the results are promising you can always get more funding to move on to bigger trials. Nobody is going to pay for you to recruit 1000 participants if you can't show an effect size with a smaller number first.
> I think its pretty obvious that a small N is not statistically significant
Well this totally depends on the effect size. You can't just dismiss results because N is small, that ignores how probability works.
>Why not use use N >= 100 or not at all.
Because N > 100 is a totally arbitrary value. The size of N that you need is totally dependent on the effect size, not an arbitrary value. You'd miss lots of real but small effects by having an N of only 100. You'd miss out on lots of real but large effects which can be observed at N < 100.
Basically this approach would severely limit the branches of research we can do, for a questionable gain in statistical reliability.
Is it really so obvious that small N is statistically insignificant? Stat sig is a method to empirically improve knowledge. Well, if it's intuitive that you need high N to get empirical knowledge, let's try an intuitive example.
Say you're a tribal chieftain. One of your men (one among thousands) finds a berry bush. Another eats a berry from the bush. He promptly dies. You're a scientific tribe, though, and you know N must be high before you conclude the berries are poisonous. So, one of the other guys eats another berry. He, too, dies immediately. The process repeats until it's you considering the bush. How does the situation change if the number of people before you was 19 vs 21?
I'm not a med sci person, but I bet if we look at the algorithms for getting to large N, all of them are expensive and all of them visit small N first. Anyway the results for any N seem very likely to be misleading to laypeople. (Laypeople means "almost everyone." For example I'm in photonics. In psychiatry I'm a layperson.)
I agree with nabla's comment that the real problem is our inability as laypeople to properly understand (or even properly upvote) scientific work.
Because you start with a small inexpensive trial first in order to determine whether the larger, more expensive trial is a) safe, and b) worth investing in.
What's unfortunate is that the research gets published at this stage beyond the scientific community that understands how inconclusive it is. Because in the long run that just contributes to the erosion of public trust in the scientific method.
I'm sorry your text is grey; this is a valid question.
These are preliminary studies: someone says, "Let me try something," it appears to work, and they report what they saw, with the resources they had.
As a result, someone organizes follow-on studies with more resources, which costs much more. At that point, the effect usually disappears, due to the greater power of the more careful study.
You're probably confusing science as a top-down enterprise rather than a field that works bottom-up (where "bottom" would be grad students). Evidence emerges and builds from below.
The criteria for what "depression" is has changed over time, no wonder our results are changing. Almost everyone has depression given the current criteria [1].
Most people have 2,4,5,6,7.
The criteria is so vague your study would have to control for each item on the list. Here, they're not even using that criteria, and instead just using a simple test which involves self-reports. Placebo could be a huge factor here.
I would highly dispute that "almost everyone" experiences any of these symptoms (note that they must happen "(almost) every day"). You've also missed a very important requirement:
"To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning."
You might accuse this definition of being too subjective. But it is certainly not something that includes "almost everyone".
> To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning.
I'd say most of the lower class has this issue.
> But it is certainly not something that includes "almost everyone".
How do you know this?
edit: maybe almost everyone is too much, I mean about 97% of the population.
Why would you say that? Do you think that rich people are happy and poor people are depressed? Anecdotally, the poorest people I know are often the happiest and the richest people are often the most miserable. I was a whole lot happier when I was younger and poorer. One thing has nothing to do with the other.
> Why would you say that? Do you think that rich people are happy and poor people are depressed?
There are numerous studies showing this, for almost all disease categories. All psychological illness is negatively corelated with socioeconomic status.
Also depression. It took me one minute to find three sources, could you please make some effort here? I have other things to do.
And you're right, it's not a causative factor necessarily, but I think there's pretty strong evidence at this point, it's hard to find a poor person who doesn't have some condition.
> Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
If most people had this symptom, you wouldn't see the current movie, gaming, and music sales. Also, sex work would not be a lucrative job, and neither would the leisure industry (except perhaps casinos).
> A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
If an overwhelming majority of people had this symptom, the world would have crawled to a stop by now. One look out the window on a busy street shows that most people are walking around normally, often at a brisk pace.
> Fatigue or loss of energy nearly every day.
> Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
These ones I could grant are extremely common, especially among the working class, and are often encouraged by moder work and management practices.
> Diminished ability to think or concentrate, or indecisiveness, nearly every day.
If this were true of the vast majority of the population, you wouldn't have any kind of political life outside the elites, you wouldn't have any real amount of productive work, and you wouldn't see any art or creativity from the working class, which is obviously not true.
Overall your claim that ~97% of the population suffers from all of these symptoms is simply obviously false.
> I'd say most of the lower class has this issue.
The lower class is not "in significant distress or impairment in social, occupational, or other important areas of functioning because they have depression-like symptoms. It is the other way around: a lot of them have horrible jobs where they are treated poorly, and that is causing depression-like symptoms (especially fatigue and feelings of guilt). It is not the fatigue that keeps them from living a better life, it is the life they are forced to live by our current economic and societal model that is causing their fatigue.
Depression manifests very differently, especially if you are close enough to the depressed person to get a good glimpse into their life. Diminished pleasure or interest does not manifest by being slightly bored while watching TV or listening to soul-less pop. It manifests by sitting alone in the dark, sleep-less, for hours on end. It manifests by simply not feeling powerful enough to get out of bed, regardless of how hungry you are, or of how important your job is for your livelihood. It manifests by crippling guilt and long bouts of crying, regardless of how important for your future it is to greet customers with a smile at Walmart. People with clinical depression rarely hold down jobs, especially if they are untreated. They rarely hold down relationships of any kind.
The symptoms described above sound vague, but they are actually very recognizable. Sure, you could say that 97% of the population has something that vaguely looks like these symptoms. But remember that this is a guide for trained psychiatrists, it is not meant for the general public to diagnose others.
Most people certainly do not meet all of the criteria you list, especially #2 ("Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day."). I can understand some confusion over #4 ("A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down)."), which can be read as describing ordinary fatigue but is actually about a different pattern called "psychomotor retardation" [1].
Applying the (current for any given time) criteria for depression requires a certain amount of training and skill, and the point form list of symptoms that you see as the first section in each diagnosis in the DSM-5 is not standalone. To mention one huge but often-overlooked example, something isn't a mental illness unless it significantly interferes with your life and functioning.
Not to say that people don't incorrectly make diagnoses all the time.
Many of these studies also rely on rating scales (typically HAMD or even PHQ9 for depression) that are a measure of depressive symptoms but don't in themselves have the power to make a diagnosis.
> Many of these studies also rely on rating scales (typically HAMD or even PHQ9 for depression) that are a measure of depressive symptoms but don't in themselves have the power to make a diagnosis.
This is my point again if you read my original post, thank you. :)
I'd go further and say the DSM-V is pretty bad at narrowing down which medication to use for depression. I know so many people on damn SNRIs whose diet is complete trash.
Totally agree on your last point. There's little connection between DSM and treatment guidelines (which do exist, separately). And treatment is so fragmented between multiple care providers (with most people accessing a small subset) that many obvious things get lost.
I think a lot of things these studies have in common is someone else is making you do self care.
As someone who has suffered severe depression on more than one occasion, in those times I know I should practice good hygiene, nutrition, exercise, sleep habits, etc., but the very nature of depression is that it takes away the motivation to do those things. If I were in a study where someone actually prepared the bath for me at a spa center, I bet I would also improve.
IMO, "fixing" depression really means fixing fundamental self-motivation, not just a transitory "oh this feels a little better".
As a personal trainer this hits the mark. People generally know what they should be doing and often need the accountability of following through with a protocol, lifestyle change, or checkups to see that they are actually following through
I think Johann Hari has the gist right: in the vast majority of cases, depression is a signal from the body of some biological/social/emotional needs that aren't being met, rather than necessarily being an immutable medical condition.
For n=1, I've struggled with (manic) depression and anxiety most of my life. And while I've used a variety of strategies to cope (Seligman's "Learned Optimism" and a potpourri of Buddhist ideas were incredibly helpful), the secret sauce was getting off of sugar and junk food. When I'm staying on a whole-foods, keto-ish diet, mood swings and unwanted negative thoughts have their volume is turned down by 90%, making the remainder relatively easy to process.
Everybody's different, so YMMV; in some cases, medication are an appropriate tool. But there are some universals that basically benefit every human: drink more water, get more sleep, go for a walk in the sunshine, eat your vegetables, and the less sugar (probably) the better.
The phenomenological impact of poor diet and harsh glycemic index ASDR cannot be overstated. 'refined sugars negatively impact mood and emotional well-being' might be one of the most rock solid universals of human nature.
All medical interventions should include the no-brainer diet, vitamins, exercise, self-esteem interventions.
As the saying goes: have you tried self-conducted sleep deprivation, exercise, improved diet, vitamin d, sun lamps, having sex, talk therapy, or any of the clinically evaluated pharmchems yet? Why not?
"Take a warm bath" suffers from a lot of the same problems as this study. You can't actually have a blind control group, so there is effectively no control group.
So this is really just 17 people assigned to take a warm bath. The thing about mental illness is that it's really really hard to be sure if something helped. You're brain is the thing that is broken, and your brain knows you are being treated.
I have depression. I've lost count of the things I've tried, and when asked, I have to say "I don't know if this actually helped or if it's just my brain thinking it should have helped."
With depression, studies which are not double-blind are garbage.
One thing to note is that the study population consisted entirely of severely depressed people. As far as I've read about it, the current consensus seems to be that the more severe the depression is, the more likely it is to respond to medical interventions as opposed to psychological/behavioral ones. This ties in to a broader understanding that depressive disorders are considerably heterogeneous and no single theory or treatment target is relevant to all cases.
So while this may be a genuine breakthrough, I hope people don't get the idea that it's the cure for depression generally.
> As far as I've read about it, the current consensus seems to be that the more severe the depression is, the more likely it is to respond to medical interventions as opposed to psychological/behavioral ones.
I've never heard this in my life, can you link? These test subjects were people with treatment-resistant depression though, which I have as well. My experience, along with others I've known with it, is that we're more likely to deal with nocebo effects. HN is tossing heaps of cynicism on this report but even for unblinded testing these results are remarkable.
> “There’s never been a therapy for treatment-resistant depression that’s broken 55% remission rates in open-label testing,” said Nolan Williams, MD, assistant professor of psychiatry and behavioral sciences and a senior author of the study
I suppose consensus might not be the right word; maybe something closer to bias or even superstition might be appropriate. But basically, I'm synthesizing my own view of several trends here. That being the case, I don't have a link that neatly sums this up. Perhaps this is even my own little hallucination. I'm only an expert by comparison to the general public, in the sense that I periodically try to survey the literature with the most open mind I can manage. But the components I'm thinking of are mostly:
1) A sense that antidepressants tend to work better the more severe the depression is. This often comes up as a counterpoint to the anti-antidepressant talking point that SSRIs "don't outperform placebo" (often, in turn, in reference to studies that directly or indirectly exclude or otherwise under-represent people with severe depression).
2) A sense that the more severe a person's condition is, the less likely that psychotherapy is to be effective, at least as a first-line treatment. There's a lot of heat over whether or why this is the case, with a common refrain among advocates of psychotherapy being that some people need antidepressant drugs temporarily in order to be able to "do the work" of psychotherapy.
3) A longstanding belief among various people in the field that "melancholic" depression is both more severe/treatment-resistant/chronic/personality-based and more amenable to biologically-oriented interventions. There is a particular thread of HPA-axis (hypothalamic-pituitary-adrenal) [1] dysfunction that has been a subject of research for decades and continues to attract interest, with a more specific clinical focus being the dexamethasone suppression test (e.g. [2]).
I hold the prejudiced opinion that most, if not all, psychology research is bogus. It's the one field with the most abuse of statistics and a crisis of reproducibility that dates back to the last century.
This is psychiatry. Psychiatry certainly respects its sister field but takes an independent look at the brain. We could always go back to the wild wild west with no psychologists or psychiatrists.
I mean, does depression even exist, or is it a psychiatric scam?
Oh, depression definitely exists. It tends to be over-simplified and is too stigmatized, but it most definitely exists. Keep in mind that "depression" is a very general spectrum disorder with many different forms. Saying someone has depression is a bit like saying "they're sick"; but they could have the common cold, flu, COVID-19, ect.
It's worth noting that there are people out there with what I'll call "inexplicable depression". In other words, everything could be going right for them. You could look at their life and find no flaws. Loving parents, deep, rich friendships, good profession, success, loving relationship with a partner, and comfortable financial situation. They seem to have it all, but just want to die.
More often there's at least some trauma and adverse experiences. On the flip side, you can find people whose lives have been and continue to be just awful; yet they're fine (or at least no depression). It's not always predictable whether someone will have problems, just like how some smokers never get cancer.
There's a scale of severity and even some people with it can't relate to everyone who has it. Someone who grew up in squalor and abuse isn't going to relate to a wealthy person with body image issues.
I've had some amount of depression myself, but I've still been unable to relate to my friends. For example, one that flunked out of college, because he wouldn't get out of bed. I've felt bad, but never to the point of letting my life completely wither away. I guess the guy just couldn't do it. He was abused growing up, experienced some relationship problems, and starting having severe issues. I have absolutely zero doubt that the person was sick. Healthy people aren't bedridden.
Posts like this concern me. You don't have to accept everything psychiatry as a field says. You can be skeptical. However, there's too much backlash to the slightest amount of acceptance and de-stigmatization of depression. Yes, it exists, you really don't want to get it, and it's a serious problem we need to keep addressing.
Maybe this just isn't a problem like doctors make it out to be. Maybe life isn't worth living. It seems like if you try to take up this position, you get shouted out of the room because no one wants to accept the fact that life is utterly meaningless and futile for a subset of people, and it's not a condition -- it's just an objective analysis of the situation.
Slaving away for 60 years and having to spend the vast majority of your healthy, waking hours making someone else rich isn't rewarding. It's pointless.
The good things in life -- family, friends, hobbies -- are sidelined and you're only allowed to focus on them 2/7 days of the week. Yeah, life really doesn't seem like it's worth living.
And that, my friend, is exactly how this mental sickness is diagnosed as a sickness: because for the majority of human beings, life is worth in and for itself, despite its suffering, nonsense and stupidity.
A healthy person wants to live. Not wanting to is one of the ways of "being ill".
And I am not shouting you out of the room: at all. Being objective requires acknowledging that most people want to go on living despite the difficulties. The inability of understanding that outlook is exactly why depression is defined as a sickness.
And being depressed has nothing to do with "slaving it" and "sidelining the good things". It has to do with BEING INFINITELY TIRED and UNABLE to COPE with ANYTHING (even those "good things" feel bad, unworthy and unappealing when you are depressed).
> because for the majority of human beings, life is worth in and for itself
Do we really know this is true? What percentage of people are just going through the motions because they don't want to cause pain to their family/friends, and what percentage of people actually just don't see the point? If suicide was culturally acceptable, or even normal, how many people would participate? Can you say with certainty that number is less than 10%? Because if 1/10 people don't see the point in living, then it doesn't sound like a disease to me.
We live in a culture that promotes "positivity" and despises "negativity," so naturally we classify the lack of will to live as a disease, but I'm not so sure that it's that far outside of the norm.
> It has to do with BEING INFINITELY TIRED and UNABLE to COPE with ANYTHING
I'm no expert, but I'd imagine at some point you just get sick of putting on the act that stocking shelves at Walmart for 60 years is your life's true calling, or that writing code to track people around the internet to sell them more useless shit is really a valuable use of your life.
Eventually you realize you're going to spend more of your life doing pointless shit than actually doing the stuff you enjoy, and that there's no escape from the system, that you're just a nameless, faceless cog in the machine, and that you actually have no real agency. So the only difference between being depressed and being healthy is how much energy you have to put up with that bullshit.
Treating depression as a disease, and not as a rational reaction to the world we live in really feels like it serves only to benefit rich corporations, VCs, private equity, etc. because if the cogs stop turning, they stop making money. Then they would have to work a dayjob, and they would understand why depression is totally fucking normal.
I have known some very intelligent homeless people who have made the same argument as you. Abandoning social expectations was their attempt at a solution. I think it mostly worked for those who dedicated their lives to chess, reading, casual volunteerism. It did not work out for those who took to drugs.
Something should be done, but trying to fix it on an individual level won't work -- you have to fix the way the system operates so agency isn't something that's reserved for a small subset of the wealthiest individuals in society. UBI would go a long way towards this, I think.
I just want to be in charge of my own life, but as long as I have to show up at the same place from 9-5, five days a week, I really don't have that ability. My life exists solely to serve my masters. Yes, I can choose which master to serve, but ultimately I am not free to do with my life what I please.
We have no agency against death, nor ability to ignore the survival needs of the body. We have little agency against many forms of suffering intrinsic to being human.
The economic requirements you mention seem small, to me, compared to the larger tragedies of life, the real limitations to our agency.
If the time sucking effect of economic needs are your primary focus, you are lucky not to be born in a prior era. I've worked minimum wage, rented the smallest room I could find, counted every penny when buying my needs. The agency granting economic power I had was objectively superior to most humans throughout history.
What have we done with this power? For the most part, we trade it for safety, comfort, security, not freedom. We trade it for entertainment, sometimes addiction. We give up our agency for more. Which is fine, my point is that the problem is not economic power, the problem is what we, both individually and collectively, choose to do with it.
You say we have the more agency than the people who preceded us, but you fail to realize the only reason that is the case is because those people reached out and took it for us. You're a bit of a hypocrite if you lavish in benefit from their actions, but fail to pick up their torch.
> We have no agency against death, nor ability to ignore the survival needs of the body.
When death becomes escapable, I can guarantee you that the escape won't be affordable for us. There are 2,000 billionaires on this planet, and every single one of them will have access to it decades before you or I can dream of it.
Their achievements don't warrant the power or privileges they enjoy as a result of their wealth, and everyone deserves a shot at that kind of success. If the game is rigged from the beginning, the winners get to run the world, and they want you to work 48+ weeks every healthy year of your life for them, what's the point of playing?
I'm not even asking for their power or wealth, I'm just asking for the same ability to pursue my own ideas with my time instead of being forced to trade my time for money through employment. We live in an era where the vast majority of "essential" jobs are beginning to be automated, and this is achievable within our lifetimes.
> What have we done with this power? For the most part, we trade it for safety, comfort, security, not freedom.
This wasn't ever our choice. As long as fields need to be plowed, and factory lines staffed, you weren't allowed freedom. The people who are in charge want you to work, so they can be rich, so they made sure you had to do something for them in order to feed yourself. Now? With automation the need for human laborers is dropping, so we can feed and house ourselves with less effort than ever before. Let's use this to free everyone from the shackles of wage-labor, and allow them to pursue their own desires with their lives, like the billionaires get to do.
> A healthy person wants to live. Not wanting to is one of the ways of "being ill".
This is the medical model of disability fallacy: someone can't function in society so there must be something wrong with them that we should try to fix--but society itself is just the same neutral backdrop for everyone. The alternative is to acknowledge that society/environment plays a big role in mental health and that because society isn't primarily structured to keep people healthy, some people will expectedly have poor mental health.
Does diabetes even exist? At some point these labels are more a matter of semantics than clear binary clinical determinations. For example, the current guideline is to diagnose a patient as diabetic if their uncontrolled hemoglobin A1c is over 6.5%. But the reality is that it's a spectrum with no clear dividing lines, significant fluctuations from day to day, individual genetic variations, etc.
Likewise depression is just a convenient label for a bundle of loosely correlated symptoms. Some patients are clearly having a rough time and need treatment. Because it's impractical to deal with subtle differences between patients at scale, psychiatrists have defined some subjective criteria to decide who should be treated as depressed.
The issue is that there is a measurement problem with many depression symptoms. You can have multiple people independently measure the blood glucose level of a patient and get the same result. And this result compares with other patients. With depression, you almost always have to rely on self-reporting or subjective evaluation by a health professional. One person saying they are depression might mean a whole lot more than another person saying it. It's not that you can't make measurements that are useful, its just that the error bars are so much larger.
> For example, the current guideline is to diagnose a patient as diabetic if their uncontrolled hemoglobin A1c is over 6.5%.
Several other objective tests can be used to diagnose diabetes. The disease could present with characteristic symptoms which match diabetes. The presence of comorbidities such as obesity also help with diagnosis.
> But the reality is that it's a spectrum with no clear dividing lines, significant fluctuations from day to day, individual genetic variations, etc.
This spectrum is called pre-diabetes. At some point, the risk becomes unacceptably high for the patient and treatment is indicated. This point has been determined through research.
Yes, blood glucose does vary during the day depending on the person's metabolic state. This variability is well understood. Normal and abnormal is well-defined. Fasting blood glucose > 126 mg/dl is evidence of diabetes mellitus. Blood glucose 2 hours after ingesting 75 g of glucose > 200 mg/dl is evidence of diabetes mellitus.
I'm aware of those clinical issues but I didn't want to obfuscate my original comment with a lot of irrelevant details. The point is that the decision about whether a particular disease is "real" or not is at some level a matter of semantics and arbitrary definitions. It's real because we all agree that it's real, and it seems to have some negative impact on the patient's life. And that's only partially correlated with what's actually going on inside the patient's body and mind. Quantitative blood tests are somewhat more reliable and consistent than subjective reports of psychological symptoms, but nothing is 100%. What level of certainty do we expect?
Depression exists. It is the most thoroughly researched psychiatric disorder. If left untreated, depression can lead to physical changes in the brain. It has enormous impact on the individual and society.
> DALYs represent the total number of years lost to illness, disability, or premature death within a given population.
> DALYs are calculated by adding the number of years of life lost to the number of years lived with disability (YLDs) for a certain disease or disorder.
There's a very interesting post Slate Star Codex about internal perception of wellbeing vs external behavior. TL;DR: there is a paper about people who claim to have experienced enlightenment, but often there's no changes in their behavior (that people around them, e.g. their friends and relatives, would notice). Scott warns against dismissing these experiences as "fake", arguing that we similarly don't dismiss claims of depression in people who are still "functional" and living their lives as usual.
The pathophysiology of depression is not fully understood. It is possible that what we understand as depression today could become several distinct diseases in the future.
In any case, the impact of depression is known and it can't be ignored. Doctors must at least try to help depressed patients. There are models which guide pharmacological and behavorial treatments employed in current practice. They are proven to be superior to placebo.
That's my point. You haven't even come up with a basic taxonomy of depression and you're already applying your theory. In physics this would be blasphemous.
> Doctors must at least try to help depressed patients.
All the help I've received has been useless or actively harmful. No one even told me to exercise or diet, in fact, some suggested I take it easy, stop blaming myself.
That was all wrong. I was to blame. Every morning, by blaming myself, I made better choices w.r.t health. Now I am no longer to blame, I have no depression.
I used to be arthritic and asthmatic, now I am biking for hours straight, doing pull-ups every day.
> You haven't even come up with a basic taxonomy of depression and you're already applying your theory.
We have no choice but to apply these theories. The alternative would be to do nothing until they are perfected. That would be negligence.
Antidepressants do not have a 100% success rate. Nothing in medicine has. That doesn't mean they shouldn't be used.
> In physics this would be blasphemous.
Not really. Plenty of theories ended up being revised when humanity's understanding of the world improved. They still had real world applications: even though they were imperfect, they were good enough for a wide variety of uses.
We don't fully understand depression. We don't even fully understand how some medications work. However, we have studies showing that by taking these medications patients improve and mortality decreases. That's enough to justify their use.
> Not really. Plenty of theories ended up being revised when humanity's understanding of the world improved. They still had real world applications: even though they were imperfect, they were good enough for a wide variety of uses.
Those imperfect theories are applied today, and still work in lots of contexts. They are complete, but subsets. We can make predictions, given certain initial conditions, with accuracy as close to 100% as you require, the only issue is measurement. Comparing psychology to physics in this manner is pretty embarrassing, and shows a lack of understanding of physics.
Applying imperfect physical theories causes bombs to explode where they shouldn't, nuclear plants to react when they shouldn't. We don't build fusion reactors today because we still need to determine the safety of isolating the plasma.
> We have no choice but to apply these theories. The alternative would be to do nothing until they are perfected. That would be negligence. Antidepressants do not have a 100% success rate. Nothing in medicine has. That doesn't mean they shouldn't be used.
I didn't say they needed to have a 100% success rate. You just need to find the mechanism. I'd be happy with a 0.1% success rate if our determination of the mechanism implies that there is no cure once it reaches that stage.
Let's do a study--I think drinking alcohol has cured my depression. It doesn't have a 100% success rate, but it would be negligent to tell people that they shouldn't get plastered if they're depressed.
edit: Don't drink alcohol to cure your depression. I suspect the mechanism is related to the gut flora. Alcohol kills the gut flora.
> Applying imperfect physical theories causes bombs to explode where they shouldn't, nuclear plants to react when they shouldn't. We don't build fusion reactors today because we still need to determine the safety of isolating the plasma.
Failures in nuclear reactors can have disastrous outcomes for a huge number of people. Is this comparable to the use of prescription drugs under medical supervision? A failure in these cases means the patient may experience adverse effects for no benefit, a risk inherent in any treatment.
> You just need to find the mechanism.
People are working on it. Meanwhile, we have make the best of what we know right now.
> Let's do a study--I think drinking alcohol has cured my depression. It doesn't have a 100% success rate, but it would be negligent to tell people that they shouldn't get plastered if they're depressed.
Again my point, obviously I don't believe this to be true, but since it does have a positive success rate (there's no study which quantifies this, strangely enough, your studies are purely epidemiological, you'd have to take someone without ASD and then prescribe them ethanol at about 20% to actually study this) it would be negligent, as per your theory/ethics, to not prescribe this, and in fact it was prescribed in the past during prohibition [1]. Now, looking back this is obviously false.
> People are working on it. Meanwhile, we have make the best of what we know right now.
Great! The best of what we know right now is simply diet & exercise, no pill can prevent the onset of depression.
I think you'll find the taxonomy of depression to be a subset of existing disease categories. The brain, gut, and nervous system are connected in a chaotic manner.
PS. I don't drink at all, zero alcohol. I agree that it's probably very much related to all existing depression categories, correlated positively.
> The best of what we know right now is simply diet & exercise, no pill can prevent the onset of depression.
Absolutely. Healthy life style decreases the risk of depression and can help depressed patients. It's standard advice.
Prevention and treatment are different though. A patient who is already severely depressed and anhedonic and struggling to leave the bed is unlikely to suddenly start dieting an exercising. It makes sense to try and improve the symptoms prior to trying this.
There are different, but they are not mutually exclusive.
> A patient who is already severely depressed and anhedonic and struggling to leave the bed is unlikely to suddenly start dieting an exercising.
I had the same symptoms, I found that exercising and dieting was the only thing that gave me pleasure (other than alcohol or cannabis). During the thick of it I would do pull-ups by walking to the bar, knocking some out (if I had a RA flare-up then I would do planks), and then collapsing after my heart-rate went back down. The issue was that people kept telling me to keep eating carbohydrate, which was causing lots of inflammation (I had tons of visceral fat). I also found that direct sun exposure improved my symptoms a ton (I was talking a D3 supplement prior).
Maybe if we told people "We have no idea how to cure this--the only proven method is diet & exercise, and this often lead to an early death if you don't start now" it would work? Once I realized that myself, it was a huge kick in the ass. I was figuratively paralyzed because no one seemed to give me this most basic advice, and the only way to get to a psychologist where I live is to self-harm.
I know a cancer survivor who was told that, and she did it, at 65, and she was obese by a large margin with severe trauma from the chemo.
I'd agree in so far as it makes pulling scams (or innocently giving useless advice) far too easy:
"I had depression, and I tried X, and it worked. You've got depression, so you should try X." Extremely unlikely to be helpful, and often can be harmful.
Hi! Lifelong experiencer of depression and several mental disorders. Am I mentally ill, or is the world really actually a horrible and callous place where most humans spend their time being negligent and abusive towards each other? At very best, psychiatrists might claim to be able to open up a wider perspective, which is why they used to be called "head-shrinkers", for their ability to humble and to remove egoist barriers, but a bit of meditation will do that too. So, is psychiatry's ability to give perspective worth the pathologizing effect that it has on people?
Why isn’t it both? There are earthy cultures around the world that don’t have a concept of ownership or the strict boundaries of western life, living in different places and cultures is easier for some and you can easily make the critical case against the western world, ill or not.
The trouble with a social intervention like therapy is the fundamental attribution error in sociology. Which character is the problem and which is the solution played out in a battle of the minds in an enclosed space. The government employed brainwashing therapist seeking to downplay any eccentricity that destabilises a social norm, or the poorly functioning client who blames others for their problems.
Therapists have a habit of dumping the responsibility for generally unsolved philosophical questions about social interaction onto the client. Where is the line between internal and external social stimuli? Who do you attribute your problems to? What is the value in a diagnosis label? Answer these questions for yourself and you’ll cure many different ailments. Fail to find the answer and remain pathologized?
Therapists routinely underserve the amount of education and philosophy required to heal. The diagnostic categories are a descriptive mess that are used as tools, yet people use them as definitions far too often.
I recommend anyone interested in therapy and ideas to see Jordan peterson’s YouTube video Self-Deception in Psychopathology (from before his fame) where he gives a quick rundown of a view above the current running mill of therapy. It tackles briefly some philosophical problems with therapy.
I like how you worded that. I definitely have my moments when cynicism takes hold and I lose most desire to do anything creative or productive. I normally power through it and double down on walking and running. It’s not a 100% fix but it certainly prevents the feeling from being my overwhelming mind state. While I guess the definition fits, mental illness seems a hard word for depression. It does seem that the tide is turning and the stigma around mental health has steadily lifted with most people.
I have mixed feelings around Psychology and Psychiatry. I still feel like there are too many doctors offering pills to cure your ailments without getting to the root of the problem. But that isn’t every doctor and I have seen things like CBT improve people’s lives. Ultimately I think that some of the “cure” must come from within and you have to want to change. I think a good doctor and therapist will help someone unload and frame things in such a way as to encourage that.
Broadly, the world is indeed arguably a horrible place. Within that context, one might hope that psychiatrists can help some with their immediate suffering.
The myopic view of treating everyone with antidepressives seems to be the result of capitalism exporting lifestyle problems and solutions to those problems, solutions that can be monetised and which create new problems. But, a big but, there is a segment of population which does need to be at some point in their life on antidepressants, clinical depression is real. These people have no reason to be depressed and yet they can’t get out of bed. We have to make sure we make this distinction though. Clinical depression cannot be denied unless one is ignorant or didn’t have first hand experience themselves or or someone close.
Where exactly is the line between the two drawn. I always got the impression that Psychiatry needed a medical degree while Psychology was similar but without one.
I'm not so sure. It depends what you mean by "depression". If you mean exactly what's written in the DSM then you should be sceptical. See "Crazy like us" by Ethan Watters: a great book, only part of it about depression.
Remember that when Freud was active the main psychiatric ailment was "hysteria". Did hysteria exist? Does it still exist? To what extent is mental illness socially determined?
It's a model. There are plenty of other models for the symptoms classified under clinical depression, human suffering is not a new thing that people just started trying to solve in the last century. Depression has some stigma attached to it, and big pharma profits a lot from it. The model and its treatments do help a lot of people, but there are an equal or greater number that they don't help. As a model it's pretty meh in my opinion but it's the best thing that modern science has come up with.
Nobody is questioning or invalidating their experiences. As I understand it, the issue is partly semantic. Is our system of labeling helping or hurting our understanding of reality?
There's an entire "field of study" that seems designed to prove that through the age-old mechanism of twisting logic into absurd pretzel knots that don't hold up to scrutiny from any but the most casual observer. It's called antipsychiatry.
The concept of a major depressive disorder exists. There are common symptoms and likely causes such as childhood trauma. Can we be certain it is a unanimous mental disorder? No, it might as well be several different disorders we haven't understood yet. But isn't that similar for most mental disorders?
It is a bad analogy. We do not know even if dark matter exists as it is one of many possible explanations of a particular phenomenon. So the depression is like a galaxy rotation speed anomaly.
Fulton Sheen has spilled a significant amount of ink against psychiatry, and against many forms of psychology, because they all reject the existence of the soul. And if the soul does exist, but we make all sorts of assumptions based on the idea that it doesn't, then all our conclusions will be tainted if not completely wrong. He talked quite a bit on depression, psychosis, neurosis, anxiety, and other mental conditions.
Incidentally, the stereotype that religion is only for the ignorant and that talking about it always devolves into an emotional and irrational argument, is only true for certain emasculated forms of Christianity, but not Catholicism, where Fulton Sheen proved that (high) intelligence is in no way contrary to religious belief, but actually religious concepts are better explained by those with higher intelligence.
Anecdotally, one of the biggest reasons I bring up religion so much, especially in threads like this, is because Catholicism was the only form of psychology that actually helped me overcome my many great mental disorders, and I am confident that it will be able to help others through their lesser and fewer forms than I had. But because of the extreme prejudice that intellectual people have against religion in general and Catholicism specifically, there has been almost no public progress in this field.
"Catholic counselors" have generally in my opinion been non-Catholic in their foundational principles and have in no way been able to help me, for example. And priests, although they should especially be educated about psychology from a Catholic foundation, especially in these days where it's more prevalent than ever (Fulton Sheen expands quit a bit on the reasoning), they have not seemed to recognize the serious need for this yet and have not caught up.
So almost all of my improvements have been from independent research on and application of these things. I really wish that the intelligentsia in general and here especially would catch up, especially when I see so many people struggling in many of the same ways I did and have overcome in the past few years. That's why I try so hard on here to convince them it's actually for them. If they only read Thomas Aquinas and Fulton Sheen they might see that it's actually more of an intellectual position than agnosticism or atheism are.
But sometimes it takes a person hitting rock bottom to realize that all their enlightened philosophy is useless to help them live a truly happy and fulfilling life. Sometimes only when we have the most pressure do we consider alternatives that may be a bit unpalatable to our preferences.
I was skeptical about depression until I saw it in my son. This is a terrible condition with bad side-effects even in a mild form. And the only effective treatment is time.
I beleive it is a scam. Every single person I've met who suffered from "depression" had a troubled past, and often a troubled present.
Not saying the symptoms are mild. It's a nasty state to be in. Inability to sleep and concentrate, leading to all sort of physical issues and impossibility to learn and keep a job.
All that being said, the causes are rather clear. Hard to fix. All these pshyco active treatments are judge bandades, anything to keep the brain quiet which in my opinion often aggregates the issue. Dependence, side effects... A person is not depressed but doesn't have its full brain capacity.
It would be valuable if clinical consultants converted to social workers to help patients address the root causes instead of prescribing medications and whatnot. Thing is, it doesn't sell that well and isn't covered by your insurance. Medics and therapy sessions are.
Have met lots of people who are depressed and don't have a troubled past or present. Your descriptions of etiologies, how medications function and help, etc. are simplistic and ignorant at best. My opinion of your opinion is not high, but luckily that's not a good basis for judgment.
See, I don't like calling it a "scam" because that implies malice. Hanlon's razor may apply here. "Depression" is our modern analogue of "hysteria" in the past; a blanket term for a wide variety of poorly understood diseases.
The medical establishment's strange resistance to exploring gut flora and inflammation as a cause of these kinds of diseases, on the other hand, is something I might call a scam.
I think that is grossly unfair, and honestly a really condescending thing to say about a legitimate area of research.
It is a messy area of work. Brains work differently between people, they work differently over time, among different groups of people, and they can rarely (outside of functional MRIs where you have structural factors) have anything but self reported outcomes. You have the privilege of saying that because people post their research and their numbers, which is all you can ask from any field of science.
There's an interesting post on Slate Star Codex (the author is presumably a doctor / psychiatrist) contrasting psychiatry ("science") with parapsychology ("pseudoscience").
Other sciences are also "messy" but that hasn't stalled progress. It may be objectively quite difficult to conduct psychology experiments, it's hard to believe that it's any harder to do psychology experiments than in other fields, mainly because I know how hard it is to actually do experiments.
On the far extreme, you have stuff like the Hubble telescope[1], LHC[2], or LIGO[3], all of which faced and overcame extreme technical challenges. Do you know how much work it took to get LIGO isolated from outside vibrations? Literally a decade.
Or consider this XKCD comic[4] about geology. "We study what's on the other side of a 20 mile thick rock wall." Similar problems exist for cosmologists and astronomers, but somehow scientists are taking pictures of black holes[5] and finding exoplanets[6].
What psychology experiments face the same kind of obstacles as these? Your subjects are not billions of light years away, nor smaller than an electron, nor whizzing by at just under the speed of light, or behind 20 miles of rock.
Yet the current state of psychology research[7] is that maybe 1/3 or 1/4 of papers can be replicated. When researchers start to explore why, they find that QRPs (questionable research practices) are common, sample sizes are small, and statistical analyses are often misused, and so on. In other words, they find the methodology is at fault, not the fundamental difficulty of the subject matter.
> What psychology experiments face the same kind of obstacles as these? Your subjects are not billions of light years away, nor smaller than an electron, nor whizzing by at just under the speed of light, or behind 20 miles of rock.
I'm not a scientist or researcher but can't this all be explained by the fact that we know much, much more about these fields than we do the human brain? And therefore, isn't it likely that at least some of the difficulty in reproducing results can be attributed to as-of-yet unknown mechanisms of the brain?
> In other words, they find the methodology is at fault, not the fundamental difficulty of the subject matter.
Why not both? And who precisely is claiming it's not a difficult subject matter besides yourself?
It's all based on self-reports, it's very hard to account for individual differences in how people answer the questions and to control for those factors. I agree wholeheartedly.
However, certain types of severe depression seem to have a biological basis. Inflammatory cytokines may play a role. The "leaky gut" theory seems to be what's helped me personally.
I had severe depression, almost unable to move, complete anhedonia. I was still doing well at work (until the unable to move part got worse), but literally nothing made me happy. There was nothing about my life situation that could have caused it.
The doctors would tell me that I'm completely fine, except my optometrist, who found that my dry eye might have been caused by auto-immune issues. I followed up with a ER doctor (I'm in Canada, very hard to find a good GP) and he ordered a newer test which determined I have anti-ccp antibodies, which signal inflammatory cytokines.
I was having stomach issues at the time, but I thought it was the depression, the primary symptom of depression is felt in the gut, or so I was told.
I found the auto-immune protocol after talking with an elderly woman who had RA. I had to cut out quite a bit of food, and found it very difficult.
Finally, I tried a ketogenic diet. Surprisingly, after one week I was feeling better! My depression lifted, though all my physical symptoms remained, I found myself running for 30 minutes or exercising without even willing it.
I then switched to a pure carnivore diet, which is a subset of the ketogenic diet. I felt even better. I've heard the Wahl's protocol is another similar method to solve this problem.
Right now, every time I eat too many vegetables, sugars, or anything high in fibre I have an issue. I think my issue was a combination of very high insulin resistance (I ate tons of pizza in my uni days) and some allergy. I think I'm allergic to dioxin and glyphosate which is sprayed on all vegetables these days. An alternative to the carnivore diet which seems to work anecdotally is the Wahl's protocol, it's just very difficult to procure and find that much variety of vegetables.
There's this MD on youtube, Ken Berry. I've found the advice he gives to be tremendously helpful.
You have 29 people in a room. The people are healthy and well. You give them a pill containing a chemical you want to test. They all die seconds after consuming the pill. The autopsy reveals they did not choke. What is the N you choose before you conclude that chemical is toxic in that dose at some p?
That's not what I said- you can still make claims against the data.
But when people are looking at N=x, most don't realize that N<30 is usually in a completely different category than N>=30. You almost shouldn't look at it as "N".
Novice "statisticians" are just (very) limited in the tools/formulas/methods available to use, because so many (entry level/basic/standard) statistical methods are only valid for normal distributions (or other constraints on data, that people typically don't check for).
Without details stated up-front, most people will (wrongly) assume that a normal distribution automatically applies, even if they don't know what that means. Similar to situations where people ask for the average/mean when they should be asking for the median.
The data isn't useless, but needs strong context and disclaimers.
I have no idea what you’re getting at here. The parent pointed out, accurately, that for large effect sizes, N=30 is plenty.
I’m also fairly certain you don’t understand what a “random distribution” is yourself. That’s because there’s no such thing. There’s a normal distribution, binomial distribution, Poisson distribution etc, and they all involve randomness. But there’s no “random distribution”.
So maybe you shouldn’t be quite so quick to judge “novice statisticians”, and what those imaginary people you mention a total of five times may or may not “wrongly assume”, or “don’t know”, or “are limited in”, or “don’t check for”.
And I didn't mean to imply that I'm any better than a novice. I just know enough to know to always check that assumptions for any given test needs to be valid. (It's been a few years since I've had to use any of this in a professional capacity.)
But is 30 plenty? Or is it sufficient?
As I remember, normal distribution usually requires a sample size of N=>30. (As in 30 is the minimum.)
On the other hand, there are so many opportunities for experimental design limiting the applicability of results in mental health experiments, that sample size and distribution doesn't even begin to touch on it. Bottom line: getting a meaningful result that is widely applicable is a horrendously complex undertaking.
A lot of times they will do small experiments to gain a sense for the data and see if it's worth doing larger experiments. Not reliable results but can still infer things.
I have also observed people suggest a statistically special N, but this is a misconception. There is no special N. There is only a relationship between increasing N and a monotonic increase in the confidence in your result. Most scientific standards specify a "confidence" of at least 95%, but if you are willing to accept more uncertainty--perhaps because there is a large upside to a positive result--then you can make due with a smaller sample.
Not to mention lots of psychology research has been done using affluent white college undergrads as research population. If you take lots of these therapy approaches outside of this demographic, they simply don't hold upto the claims made in original research papers.
Agreed! Asking people how they feel and jotting that down on a piece of paper isn't science. Similar to social and nutrition "sciences" that gear more toward PR angle and "number of news outlets talking about my paper" than legit science.
They should all be relegated back to the arts and crafts.
Most if not all? That's an interesting statement. If you said all I would assume you do not swe pjsychology as a testable science. What kind of studies do you approve?
It looks to be a form of TMS which has already shown a lot of promise for several mental disorders. I wasn't able to look at what they changed specifically, but TMS itself is rather safe.
Instead of one long treatment in a day repeated for up to six weeks, they made it higher intensity, ten times a day, ten minute treatments on a day, repeated with patients seeing difference in three to five days and they used an MRI to target an exact location in the brain for each patient.
Not to get to into it - but last summer I had a bad episode and was recommended to ECT therapy and/or TMS (I have some other mental disorders that would also benefit from TMS). My biggest problem with both of them was that for TMS I'd have to travel a distance everyday for a month, with ECT it would only be a few times a week but somebody else would have to drive me, and it's not recommended to work during that time.
So this would be a game changer for me - I can take a week off no problem.
On safety: I'm no medical expert, my understanding is that why TMS works is not really well understood (similar to SSRI's and other antidepressants) - we just know it _tends to work_ and we have some theories for why. So from my naive perspective higher, more concentrated doses certainly sounds like it has the potential to be more dangerous - but that's just speculation.
Modern ECT causes temporary confusion and short term memory issues, but my understanding is that they generally clear up after treatment. However, it's a month long treatment, and it's not advised to work or drive during that time. I don't think long term memory loss say several months after treatment is a common problem, but I could be wrong.
To my knowledge TMS doesn't have those memory issues.
Please keep in mind that modern ECT is nothing like what people see in the movies. While I'm not at all saying it should be a first tier treatment, it's a treatment option for those with otherwise treatment resistant depression (and also a few other disorders)
I was personally referred for ECT therapy last summer by my psychiatrist. I was in the middle of a massive depressive episode, had already tried a ton of different medications (and took a break from meds to see if that would help - it didn't), diets, etc. I even mentioned to my doctor I was to the point where I was potentially thinking about self-dosing on psychedelics or ketamine because I felt I had no other options. At that point ECT therapy even with bad side effects (which again to my knowledge don't normally last forever) would be better then suicide.
I didn't go through with it because I'd have to take a month off work, and get transportation to the clinic several times a week. Personally if it gets that bad again I'm going to try to get TMS therapy, as I'm also on the ASD spectrum, and there's been some evidence that suggests it may help those symptoms as well.
A 90% response rate is in-line with ECT on non-medication resistant patients, actually, and it's not historically out of place that TMS performs so effectively. [1] [2]
Historically, TMS has had lower response rates than ECT, though this trial seems to offer a less invasive treatment with a comparable response rate. The measured response rates of the initial trials tend to drop after testing in a larger population, but it's great to see TMS progressing with improvements identified regularly.
I thought I read that some vets who received TMS treatment for PTSD still had some pretty severe mood disturbances/personality changes. I don't know if it was clearly established whether those symptoms were entirely consistent with PTSD, or whether the particular doctor responsible for many of the cases was 'doing it wrong' and needs to have his license revoked.
I suppose like most medical treatments, if the cure has a small enough probability of being worse than the disease, we will use it anyway and work on ways to deal with the side effects when they arise.
placebo is 30%-50%. Even if they invented a super placebo that worked for a while, thats pretty cool. As long as it doesnt cost millions of dollars to use.
As soon as I saw "magnetic stimulation" I was a tad skeptical as they've already achieved this with brain electrodes in the past. The difference is it could actually be practical, on psych visits. I see it as a stand-in for medication with all sorts of side-effects. Not a solution mind-you, just a way to bridge the gap to recover, which is what medication is meant to be.
EDIT: a stand-out line: "One month after the therapy, 60% of participants were still in remission from depression. Follow-up studies are underway to determine the duration of the antidepressant effects."
TMS immediately dials my skepticism up to 11 as well. But there's some fairly good evidence that is helps people who suffer from migraines with aura. From what I understand, it has something to do with increased cortical excitability in migraineurs, and TMS is somehow able to reduce that effect. I don't know how this would translate to depression treatment, but it's interesting nevertheless.
Reading some of the comments is a good reminder that solid and meaningful mental health research is very tough and expensive, just based on the sheer variability, which can't be meaningfully captured by 99.9% of studies. Each needs to be seen as one piece in a much, much larger puzzle.
> Intermittent theta-burst stimulation (iTBS) is a noninvasive brain stimulation treatment that has been approved by the U.S. Food and Drug Administration for treatment-resistant depression.
If this is anything like Neurofeedback treatment, it wouldn't surprise me that it is effective. Neurofeedback treats 3 major frequency ranges of the brain, Delta, Theta and Alpha. Although this treatment seems passive whereas Neurofeedback treatment requires active modulation and stimulation by the person getting the treatment.
Going through Neurofeedback treatment myself and seeing the incredible life changes because of it and now seeing the similarity of the affected brain regions in this study shows that there might be some consensus reached on treating these conditions without medication one day.
I found out about it in this book The Body Keeps the Score[1]. Its a massive book, so I would just focus on the Neurofeedback section. But it doesn't have the first hand experience so mileage may vary.
By co-incidence the researcher that pioneered this breakthrough treatment was located in the same city as me. You can see some of the videos[2], but it will be difficult to understand and appreciate unless you spend a lot of time reading papers and learning about the brain. I will say its worth it to learn, especially if you want your ability to focus to go from below average to far above average. Feel free to email me if you want details, I had to become well versed at it out of necessity more than anything.
This is some of the worst HN commentary I've seen. Boundless cynicism on an early study which is actually showing unusually high success rate. What's noteworthy is that the these results are good among unblinded studies on depression treatment. They are doing a double-blind study right now, mentioned in the second sentence. These were patients with treatment-resistant depression, which is defined as people who have undergone multiple treatments without success and are rife with nocebo tendencies. These are not people who are hopeful about their nth medication or round of talk therapy. They are tough nuts to crack. That the treatment is showing any success with this group is worth doing further studies.
This new form of rTMS appears to have truly incredible potential to help people whose depression is otherwise resistant to treatment, which is sorely needed.
Having over 85% of participants meet remission criteria is, to put it mildly, incredible, though with only 21 participants, sample size is too small to make conclusions regarding large scale effectiveness.
As the paper notes, we now need double-blind trials. I very much hope that this treatment will be able to help people on a larger scale.
These incredible numbers will almost certainly drop in larger trials and once more medication resistant participants are included in a study. ECT is comparable to the efficacy of this small scale trial, but their novel approach and increased dosage could yield a major improvement to TMS.
Placebo effects can play merry hell with depression, and even moreso when the patient is treated with fancy technology that has a noticeable side-effect.
Sounds interesting. I wonder what’s the best way to try such a treatment without first spending tons of money and energy dealing with insurance and doctors.
This. It sounds like this should be the FIRST thing to try, rather than the last. Sadly this is not very likely how it is going to be for a very long time.
The protocol is actually fairly intensive and expensive, involving tailored brain scans and all-day treatments over multiple days. It's the sort of thing that I could see in inpatients or partial hospitalization patients, or as an intensive outpatient protocol. You'd basically have to take off a week and go in every day all day.
This is promising but it's not randomized or controlled so hard to make anything of at some level (you can see how this kind of protocol would induce massive placebo effects).
If there is an effect, it may be that some kind of mild version of it, say, for a day or half-day or something might be useful in more mild forms of depression. But it's an intensive expensive treatment in its own way so might be hard to implement as an initial intervention.
But I agree that if it works this well it might be worth it to take a week off or a couple of days or something.
Individual TMS is really interesting. My understanding was that most large-scale TMS was untargeted and not really that effective.
I was about to write something about a side effect I had read, which was about people losing the ability to swim, but that apparently a DBS (deep brain stimulation) side effect for tremors from parkinsons.
> The researchers are conducting a larger, double-blinded trial in which half the participants are receiving fake treatment.
This second sentence from the article is enough: let us not comment on an experiment that had no control group. I will be interested in the results from the second trial though.
Important note: this result is not from a randomized controlled trial, and have been done on small number of subjects. The article mentions that the researcher are designing a larger and proper trial.
Here is a short interview with comedian Neal Brennan about his personal experiences with (40 30-minute sessions) of Transcranial Magnetic Stimulation. He says it was more effective and longer lasting than Ketamine Therapy or Zoloft. He was able to stop taking Zoloft.
Assuming, on the off chance, that this isn't some sort of quack treatment ploy, anything that works significantly would be a plus.
I'm on my 13th antidepressant now that is yet-again not working well and I'm starting to wonder if my condition is inflammation-mediated rather than receptor- or neurotransmitter-caused as only mirtazapine (also a powerful antihistamine) ever helped me significantly, but only for a limited time.
Obvious disclaimer that every depression is different.
My depressive symptoms have never been medicated yet I'm pretty sure are inflammation-based: changes in my diet drastically affect my mental and physical well-being.
Exercise, lifestyle changes help, but diet seems to be the primary cause and solution in my case.
Is there further documentation about this, or other papers I can read? This part in particular seemed counterintuitive to me:
> “The less treatment-resistant participants are, the longer the treatment lasts,” said postdoctoral scholar Eleanor Cole, PhD, a lead author of the study.
In the context of the press release it was a little confusing to me because the published paper doesn't really report on anything that would be considered long-term. I assume she meant something like "the less treatment resistant, the more pronounced the effect"?
Treatment resistance probably refers to prior treatments, which is a sort of indicator of severity or, well, resistance to treatment. So it makes sense to me that people who were less resistant to prior treatments would show more immediate longer-lasting effects.
But it's confusing.
This is impressive but it's not a randomized controlled trial at all, and it's a fairly select group of patients, so it's hard to know what to make of it. TMS treatment of depression has kind of been plagued with publication bias effects -- not to say there's no effect but more rigorous meta-analyses have suggested that publication bias is significant in the area.
Sometimes with very severe patients you see more regression to the mean, in that they have bigger apparent improvements in control conditions just because they can only stay the same or get better.
I think she means "the less treatment-resistant the participants are, the longer the treatment remains effective" (not that the session drags on longer).
The results of this study are pretty exciting, but the idea of using various forms of TMS to treat depression has been kicking around for a while, and several groups have been trying to optimize the stimulation in different ways.
I'm not sure exactly why, but common sense would state that, with treatment-resistant participants, you already know "1000 things that don't work", and so you've narrowed the search space.
If the way they're doing this treatment involves hitting the subject with magnetic stimulation in "all possible parts of the search space" that might potentially solve the problem, then if you've already half-treated a subject (stimulated one entire side of their brain, say) and it didn't work, that means both that they're "treatment-resistant" and that the second treatment should only focus on the other half of the brain.
If stimulating some part of the brain can increase neural activity in a lasting way, could you use this to, say, make yourself better at math? Or, could you use it to suppress unrest by making everyone happy? If this works there are a lot of larger implications.
Do I understand correctly that they basically:
1. find the subpart of your brain that causes you to be depressed
2. use TMS to essentially block that region from being so active
?
Wonder if you could use this one day also for the regions that cause me to e.g. procrastinate...
I've done transcranial magnetic stimulation for my bipolar depression. Didn't seem to help. It's a pain to try to work and go for treatments every day. Meds work better for me.
Well. If you have depression and you’re a business owner or small trader for example. It would be impossible to get out of bed some days and feed yourself. So id say it’s one of the most important financial fixes for every human.
You took it as if it needs to be a fix just so people can be happy. Happiness doesn’t mean you’re surviving.
Yeah I agree, depression is a bigger deal than those things. But there's also heart disease, obesity, etc that are along the same tier of health issues with massive impact. But the #1 biggest issue imo is the length of commutes. We would all be so much more productive if we would all move to perma-WFH.
If we could get rid of depression a lot of other things you mentioned would go away too. A lot of unhealthy lifestyle comes from lack of clear thinking and escapism.
That's great until you find someone with underlying psychosis and the voices in their head after a few months of treatment tell them to take out a big knife and go for a murder/suicide.
It's great for the people it works for, but Spravato/esketamine isn't for everyone.
As someone who has schizoaffective disorder, I take offense to your assertion that psychosis=murderer. Your claim only serves to perpetuate the stigma attached to psychosis, when the disease itself is already bad enough. Coincidentally, I happened to have taken ketamine infusions for depression long before I was diagnosed with schizoaffective.
No, and I cannot fathom why you would believe that could be implied by my response.
Lots of people are reading things I didn't write. I merely asserted that there exist people for whom Spravato/esketamine is not the answer and related my own experience with having someone very close to me treated with it. That's it. Every other random implication is from someone reading things that I didn't write.
And it's sad, because esketamine really looked like a good treatment at first. It made real improvements for a while. As you might imagine, it was discontinued immediately after that incident.
Since this isn't double-blind, I wonder if there's reason to upvote it to the top of HN now versus after the research progresses a little more.
Sometimes early signal, even if inaccurate, is very valuable (e.g. bitcoin). With alleged medical advances, I almost never find that to be the case (I can't recall the number of times I've read about cancer being beaten here).
This reads as extremely ethically dangerous.
I'm not sure it's possible to justify any course of treatment leading towards individual neurocircuitry 'tweaks', even for an unambiguously good cause.
Harkens too closely to 'scientist seeks to cure homosexuality through direct brain stimulation' in the 1950s.
( en.m.wikipedia.org/wiki/Robert_Galbraith_Heath )
Isn't every treatment we have for depression some form of neuro-circuitry tweaking? Whether you're using prescription medication, electroconvulsion, psychosurgery, counselling or self-medicating with legal or illegal drugs, you're deliberately altering your brain function in the hope that it'll result in temporary or permanent changes to your feelings and behaviour. What makes this procedure more ethically dangerous than those?
>Harkens too closely to 'scientist seeks to cure homosexuality through direct brain stimulation' in the 1950s.
Let's say we lived in a world where in addition to having their sex changed, people could have their gender and sexual orientation changed. Would there really be anything wrong with that? In the 1950s, it was a forced medical procedure, but what if the wrongness came from its involuntary application and not its intrinsic nature?
Yes? Do you approve of the idea of using any combination of therapies found effective to cure people of believing in their religion, or to 'solve' political dissidents?
Intellectual freedom,literally in this case, is important.(1)
>Do you approve of the idea of using any combination of therapies found effective to cure people of believing in their religion, or to 'solve' political dissidents?
What I'm suggesting you consider is, what if it's only done voluntarily? For example I can't imagine a political dissident voluntarily subjecting themselves to belief neutralization. I have a hard time imagining how the voluntary rule could allow any of the authoritarian outcomes.
People who underestimate it actually make me angry. Not only does it take your life away, it takes it away and leaves a giant black hole, and I wouldn't wish it on anyone.
Is there an outside definition of medical ethics that can really be impartially compared from generation to generation?
I'm certain all previous generations thought they were acting in good faith as well.
Progress towards 'changing people's minds' is dangerous for the same reasons across all times and places.
>Is there an outside definition of medical ethics that can really be impartially compared from generation to generation?
That's a legitimate criticism of doing anything, but the problem is that it applies to, well, anything. Anything you do today could be seen as a horrifying atrocity by future generations, unless there exists some kind of boundary on what ethical stances a culture might adopt. There could be limits, but in that case there is an outside definition of medical ethics. If there isn't an outside definition then maybe in 100 years haircuts will be seen as mutilation[0].
[0] There are some cultures with strict rules about facial hair, so even though this example might sound ridiculous it actually serves to illustrate the point.
(if the study replicates), the targeted precision and long term persistence of therapeutic effects. If someone prescribes you a pill for being gay and you don't want to be cured of being gay, you could always just stop taking it later if you were able to leave the despotic regime / cruel family structure / religious community binding you.
In all three cases, you've got a specific "associative" pathway that's bothering someone and interfering with their lives, that they seek out treatment for; and in all three cases, the solution is to get their brain to just not activate that specific association any more, in effect just ripping/burning out the synapse that causes a memory of X to in turn activate emotions or memories of fear/shame/trauma/etc.
I say "in effect", because the brain is electrochemical; and so it wouldn't seem to matter whether you blow an association away at the electrical level (by e.g. physically removing/necrotizing/calcifying the synapse-as-"wire", as ECT does; or by increasing its "resistance" by reorganizing it at a molecular level, as TCM probably does), or you do it at the chemical level (by e.g. re-training nearby junctions so the "carrier signal" feeding into the synaptic junction is too "noisy" to pass signal along, so even if the path activates, descending connections don't receive useful information from it, and so learn to ignore it; and/or by temporarily starving/blockading the ion pores it uses to receive voltage-generating ions through, starving it of its ability to work as a transistor for the signal it wants to generate—until, again, descending connections learn to ignore it, even when it comes back fully functional after removal of the blockade.)
But, as a separate ethical argument, I'd like to also point out: people do, obviously, have the right to self-modify their neuronal architecture. They must be fully informed and consenting as to the consequences of such, and must want those consequences—think them better than the alternative, than all alternatives. But then they should be allowed to do so. And, since they—as lay-people—can't do so by themselves, trained specialists should be there to help them to safely perform the modification they want to perform.
That's the same bar that a patient already has to pass, to qualify for e.g. hormone-replacement therapy targeting gender dysphoria. Medicine already has an infrastructure for ensuring patients want what they want, here. And that infrastructure (mostly coincidentally) already prevents doctors from just deciding to do these things to patients without the patient putting in the effort themselves to go through this "one thousand consent forms over a space of months" rigamarole.
(Many people might say, in fact, that the existing infrastructure sets the bar too high—for example, that doctors make demands of patients to prove specific preferences over desired outcomes of treatment that align with the "on-label" use of the treatment, rather than accepting patient requests to use such treatments for their well-known "off-label" effects. In the HRT case, many people who identify as non-binary want to get HRT for their own reasons, but some doctors don't want to give it to them, because it's only indicated for a specific kind of gender dysphoria related to wanting to achieve a clear end-state of a binary gender.)
Moral problems arise not from curing suffering being morally wrong, but the leakage of moral responsibility in medical/psychiatric practice outside of research.
Any tool to 'correct associative pathways' will be used for the conversion therapy of children, punishment of apostates by repressive states, and torture of the criminally convicted within one generation of it's inception. My primary hope for the memory reconsolidation therapies require some kind of actual moment by moment deliberate cooperation by the treated, and can't be performed without an expert (hopefully) bound by professed vows.
I don't see the argument. Pretty much anything can be used for torture. Taking tools of torture away doesn't do anything to stop torture—you can, ultimately, torture somebody (all the way into full-on brainwashing!) with nothing more than your own words and hands. That's how domestic abuse works, usually!
The ethics of state-sponsored torture (and/or state-sponsored "mind control" like conversion therapy) are fundamentally political ethics—i.e. the ethics of choosing which political "machinery" to build, where different formulations of a state can ensure to different degrees that any given (ultimately self-serving) state apparatus will be properly bound to human rights, and properly watched over by people empowered to see and report any human-rights violations that arise.
The use of psychiatric techniques as torture is the history of psychiatry. This is not some petty joke or argumentative stance.
Do you think that Henry Cotton was a problem of political ethics? Supposedly his reputation and political status were so high in his society that patients and their families actively asked for their teeth, gallbladders, ovaries, testes, tonsils, ... to be spuriously removed.
Edit: I mean to say that serious contemplation of the risks and benefits of any medical interventions should always be taken seriously regardless of how severe a medical problem might seem or how exciting a miraculous new cure might appear to be. Most miraculous cures not only don't 'work', but also caused serious harm to their subjects throughout the history of psychiatric medicine.
n=21, no control group, zero blinding. Placebo response is notoriously high in depression studies, so it's unacceptable that they didn't include a control group.
This technique is a variant of rTMS, which has been around for a long time. We've had years of positive rTMS study results that failed to replicate in real-world conditions. There's some early evidence that it might do something positive, but it's not clear that it's a viable treatment option. In most major cities you can usually find at least one obscure rTMS clinic somewhere, but they won't offer the exact rTMS technique studied here. They also won't give you 50 sessions across 5 days as used in this study.
It's very disappointing, even suspicious, that they didn't include a control group. It's trivially easy to include a sham rTMS treatment because the patients can't see the magnetic field. At minimum, they could have split the group into low-dose and high-dose to demonstrate a dose-response relationship. Yet they deliberately chose to avoid any control group or dose-response measurements.
I can't access the full text, so I don't know when they measured the patients' depressive symptoms. If they scored the depression inventory on the final day of the 5-day treatment, this wouldn't be very promising as a long-term treatment. The real test would be how the depression remission holds up after the rTMS treatment is discontinued. If the remission persists for months, that would be truly impressive. On the other hand, if this only works with 50 in-office rTMS sessions per week, it's not a practical outpatient treatment.
I would love to be wrong and for this to be the holy grail of depression treatment, but given the circumstances I think it's best interpreted as an outlier study unless/until someone else reproduces it. I don't think we'll all be going in for 50 sessions of rTMS across 5 days any time soon.