No problem worth solving has ever been solved 
    on an Internet forum.

I am not likely to respond to attempts at refutation to my mantra. You see, I have this mantra...

    No problem worth solving has ever been solved 
    on an Internet forum.

First of all, depression is characterized by people who have distorted thinking about themselves and rationalizations for avoiding treatment. So that discussion is going to be necessary to have.

Secondly, it's reasonable to be skeptical about psychiatry and self-help books. The industry is saturated with snake oil. One has to rely on one's own judgment or one would be endlessly drowning in research. Judging books by their cover isn't just appropriate, it's mandatory.

Sometimes literally. One of the best-selling self-help books for CBT depicts a guy with a lobotomized smile floating in a dreamy cloudscape with the title "Feeling Good".[1] When it was prescribed to me I was disgusted. It looks like Stuart Smalley.[2]

But people who made the same mistake were corrected by others who had read research, or had personal knowledge. Which leads me to my last point: head-butting has its place. In the wild, animals who butt heads are doing so to determine which is the stronger, without actually engaging in wasteful combat. Similarly we are often arguing to probe which argument might be better, without fully testing it. It's enough, sometimes, to sense someone's confidence, to see a glimpse of the detail of their knowledge, even if they don't cite anything.

That heuristic is highly exploitable by people who have abnormal abilities to project confidence (aka, "confidence men"). But it's all we've got in a world that none of us have time to fully investigate.

At the very least, in that discussion, I hope people learned they couldn't just dismiss CBT out of hand; intelligent and experienced people had decent arguments for it.

[1] http://www.amazon.com/Feeling-Good-Handbook-David-Burns/dp/0... [2] http://schlegelrock.com/wp-content/uploads/2011/03/stuart-sm...

You're right about the image, but the book is worthwhile.

[1] http://news.ycombinator.com/item?id=4509281

[2] http://www.ncbi.nlm.nih.gov/pubmed/2738212 (The book is not cited in the abstract, unfortunately, but I believe this is the correct study.)

I've found that to be good advice in general, and for internet conversations in particular. Start with the assumption that you are communicating with someone who is not an idiot, who has something to say, and try not to give reflexive, dismissive answers.

Not that I'm so perfect as to always remember, but I try.

It doesn't surprise me that the same thing happens with medical or other types of advice.

The bottom line is, don't take advice on anything specialized over the internet. Talk to a specialist, or do the loads of research yourself that it requires to form an educated opinion.

So "stop reading these and ask an expert" is obviously a good piece of advice for someone seeking resolution of their own serious problems but there's still value in reading internet discussions.

You would do well to avoid appeals to authority in scientific matters. It happens that a recent meta-analysis demonstrates that depression medications simply do not work for the majority of people.

It seems that, over the years, Big Pharma funded a lot of studies of depression medications, and systematically threw out those that didn't support their position:

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fj...

A quote: "Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance."

Read the last sentence carefully. It means the depression medications don't work any better than placebos for the majority of people. This is perhaps the best-kept secret in psychology.

The nest time you're tempted to say, "The matter has been studied. There are papers. There are books", remember this study -- it summarizes all those papers and books, and shows that these drugs do not work.

Which is exactly what one would expect.

Second, this paper is not without its critics (just look in the comments):

"Huedo-Medina et al report that decreasing placebo response with increasing baseline severity of depression is their paper’s “unique contribution”. However, it is clear that this is an artefact of using the standardised mean difference. Analyses using the raw HRSD scores reveal that mean placebo response remains constant with greater response to antidepressant treatment with increasing baseline severity".

Thirdly, you do a disservice to psychologist and psychiatrists if you believe they are further behind on their reading than either you or I.

Yes, and they came to the same conclusion that I stated in my original post -- for the majority of people, antidepression medications do not work. This is a fact that's being kept out of the public's view the the degree possible.

But those efforts seem to be eroding:

http://www.usatoday.com/news/health/2008-02-26-depression-st...

A quote: "Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients unless alternative treatments have failed to provide a benefit."

> Second, this paper is not without its critics ...

And that is the way it should be. But until the critics perform their own studies of equal quality, the result stands. This is how science works -- authority means nothing -- evidence trumps eminence.

> Thirdly, you do a disservice to psychologist and psychiatrists if you believe they are further behind on their reading than either you or I.

Believe me when I tell you, based on my voluminous correspondence with psychiatrists and psychologists, they aren't very well-read at all on this topic. That is how they justify writing all those prescriptions for ineffective drugs.

As participants in an online community, let's try to help one another. Raganwald has been very constructive in discussions about depression treatment here on HN. I try to do the same, and am always happy to upvote one of his stories or comments on the issue. One of my most disappointing memories of my early participation on Hacker News is hearing that Dan Haubert of Ticketstumbler (HN username "fallentimes") had died.

http://news.ycombinator.com/item?id=859117

Just shortly before that, there had been a thread here on Hacker News in which too many users were taking the point of view that people who seek effective medical treatment for depression are weak or fools, and that they should just man up and not talk to a doctor about how they are feeling. I'd hate to think that someone here pushed fallentimes to taking his life, by trash-talking the help that anyone feeling depressed can seek from professionals.

The paradox of mood disorders is that they are disorders of thinking, either being glum beyond the warrant of objective life facts (depression) or elated beyond warrant (mania). Prescribed medication is one means, and thoughtful cognitive therapy is another means, to help people who have mood disorders get back in touch with the reality of their lives and go on coping with the uncertainties of human life. The prescribed medicines usually work more effectively when combined with the cognitive therapy, and cognitive therapy, which is very helpful, often meets a person's needs better when the person is also taking prescribed medicine.

Because the human brain is enormously biochemically complicated, and because mood disorders are largely a disruption of a complicated regulatory system ("mood" has many interconnections of cause and effect with other aspects of human behavior), it is currently hard to predict which medicines will be helpful for which patients. Sufferers of mood disorders do not all have the same genetically influenced biological substrate for their difficulties in mood regulation. So part of medical practice in dealing with depression is still quite empirical--prescribe a first-line medicine, and see if it works, and then try something else if the first medicine doesn't work or if it has debilitating side effects. Patients who have a history of both low and high mood states have to be particularly careful in choosing medicines, because some effective antidepressant medicines can prompt episodes of mania. (Some medicines are categorized as "mood stabilizers" and are helpful for the downs of depression and the ups of mania.) But doctors who have a strong clinical experience base can help patients a lot with advice on which medications to try first, and many patients benefit soon after starting medication by being much better able to gain from cognitive therapy and much better able to cope with life stresses.

By the way, repeated studies of life stress and its relationship to mood disorders show that generally people who suffer bad mood disorder symptoms are persons who have more stressful life events (family, employment, housing, or other major changes) than related persons who have don't fall victim to mood disorder symptoms. And the usual twin study methodology and other behavioral genetic studies show that mood disorders plainly have some genetic influence, although genome association studies have yet to show ANY particular gene with a strong effect on mood regulation. Simply put, mood disorders appear to be a polygenic, multifactorial disease with diverse underlying genetic vulnerabilities leading to greater risk from life stresses than some other people undergo. More research on the issue is still being done, but meanwhile seek competent current treatment, and don't give up.

http://www.lambdassociates.org/blog/bipolar.htm

An example: I used to tell my therapist that whenever I was in a social gathering I felt as if I was getting negative reactions from everyone and that I wasn't wanted. Keep in mind, these people invited me to be with them, I didn't tag on.

The main problem with this thought pattern was that you can't "feel" that you are getting a negative reaction. You believe you are getting a negative reaction. I logically understand that I'm not a psychic. I do not know what these people are thinking, yet I believe they don't like me, even though they are inviting me to hang out with them. That doesn't make sense does it.

This is just one example of many.

As for the medication, it worked wonders. I had to try out different types however. The first medication I tried was welbutrin. It worked at first, I actually though about happy things. Probably something most take for granted but it felt like night and day for me. After going up in dosage however it made me feel more like a machine. Then I switched to prozac and have been going strong since. Prozac is working much better for me. I feel normal. Not sad, not necessarily happy all the time, but I am not having extreme pain inducing headaches 5 times a week for hours on end.

One of the ways my therapist framed using medication to me was that if I wasn't depressed the medication wouldn't work first of all. It doesn't magically make you happy. Also, if you are actually depressed, you have extremely low amounts of certain chemicals in your brain that are necessary to properly function. So it's not like you don't have an actual ailment that requires treating.

Also, to those that claim that you can get better from depression by eating better, excersize and sleeping. It's very difficult to put in that sort of effort when you can't get out of bed.

To add: The main thing I want people to get out of this is that we need to remove this negative attitude towards getting treatment for things like depression. I imagine a ton of people that would have gotten help if they weren't afraid of being perceived as weak especially to themselves. Cognitive therapy wont work if you go into a session and expect nothing out of it and are completely uncooperative.

She feels that people don't like her. She also gets extreme pain inducing headaches several times a week (which I actually thought she should treat separately, I didn't relate it to the first). She also shows other symptoms (lots of time spent on Facebook doing nothing, she only works 20 hours a week and we have no children)

She recognizes she's depressed (which I think is a huge positive), but she refuses to seek outside aid (and she's a psychologist with a postgraduate specialization in learning disabilities).

I've also failed to convince more distant relatives to seek aid.

How would you go about convincing someone to seek outside aid?

At least she recognizes it, and I think she's slowly getting out of it.

I am glad everything worked out for you!

I don't think lifting weights is a good metaphor for mental health.

So because of this, you're hesitant to point out that another person is incorrect on the internet. You don't want to enter a flame war for fear of losing face.

http://raganwald.posterous.com/how-to-win-friends-and-influe...

I believe that in the long term, personal credibility is bolstered by wins and losses are forgotten. So I'm happy to risk losing face in exchange for once in a while saying something that might be a big win for everyone on certain subjects, like programming.

Depression is different. It probably works the same way where karma is concerned, but the difference is that with programming, I am motivated by getting people to think. If they try some hair-brained programming scheme like "The Williams Style:"

https://github.com/raganwald/homoiconic/blob/master/2011/11/...

I don't lose sleep over the result: They are adults, they made a choice, they are smart enough to rewrite/refactor, they learned something, their colleagues can stop them, &c.

With Depression, I am motivated by people's outcomes. If I tell them CBT is wonderful but it doesn't work for them, I might have steered them towards a very poor outcome. It may not be so easy to just start all over again. I fear giving bad advice about depression because I believe the consequences are far more serious than writing conjectures and anecdotes about programming.

With programming, I sincerely believe that a beautiful failure is a win unto itself. With depression, a failure may have fatal consequences. This isn't a face or karma issue for me personally. I can't speak to anybody else's eagerness or reticence to speak to programmin or depression.

    To make things worse, the experienced person hesitates before wading
    into an Internet debate, while the inexperienced fanatic takes typing
    classes so that he can reply to everyone within 6 seconds of their
    posting a comment. So the debates are dominated by the people least
    able to offer insight.

Oh, dear.

I'm guessing that they have some sort of publish to static HTML worker that is ignoring my blog, but in the spirit of my post, I'll try not to speak out of ignorance :-)

It is entirely the wrong kind of anecdotal evidence, dominated by the least experienced people, under the worst possible circumstances: Pseudo-anonymous debate where you win points for getting people to click a little up-arrow and you have zero emotional investment in what people do with their lives.

Perhaps, but this diverges from the point you started with, which is that many people with whom one disagrees act as they do because they are trying to offer their insights for the benefit others. And for the most part, their intentions _are_ good. It's offensive (and I think wrong) to say that those who dominate are the least experienced or not genuinely concerned by how others will be affected.

I think that bad_user's comment about concentrating on the self and not properly considering the effect on others has merit, and should be discussed. I read Seligman's Learned Optimism based on the recommendations of you and others here, and felt I must be missing something. I went to a half dozen group CBT therapy sessions, and felt that I never connected with it or the group. The sense of "selfishness" I got from it concerned me, and was part of what turned me off.

I think CBT is probably effective for many, and probably could be for me as well if I could get beyond feeling that for it to work I would have to toss aside too many of my moral values. Rather than becoming more perceptive of my thought process, I felt that I would need to desensitize myself to self deceit, and give up my sense of truth. So for better or worse, I stopped going, but continued with the medications.

Still, I appreciated (and still appreciate) your recommendation of the book, and your willingness to share some of the ways it benefited you. I'm glad I read it, as it gives me greater understanding of the thought process behind CBT. Had I started with just the therapy, I probably wouldn't have bothered with the book. And I wouldn't have read it if you hadn't made clear that you were recommending it very strongly.

Which brings us back to the start. I read your post, I evaluate your recommendation, and I choose to act. I presume that you are acting with good will and in good intent. If instead I presume you are acting with ulterior motive and lack of concern for others, I miss the benefit of the discussion. And if you hang back and let the loudest dominant, I miss the benefit of your insight.

Engagement between different parties with different viewpoints, each offering their own solution, is the goal, not something to lament. What works for one doesn't work for all. bad_user may be wrong, but the best we can hope for is that his intents are good. It's when we stop assuming that that the communication and learning stops.

So if that one comment struck you as having some merit, what I hope is that you say, "Hmm, there's something to look into" rather than "Aha! Obviously it's bad."

You run into the same thing if you talk about panic, because a lot of people think of the low-level anxiety attacks that everyone gets, not the intense kind that literally feel like you're drowning in air.

I think the problem is that our society (especially in white-collar workplaces) measures people based on a war of attrition. Most companies intentionally create unnecessary stress and promote the last people standing after the rest develop mental illnesses (usually the mild, situational kind) that cause them to be unable to perform. The losing competitors are the ones who experience stress-related, career-rupturing anxiety or depression. (Sometimes this is called "nervous breakdown", but I fucking hate that phrase.) The winners are the ones left over, who are taken to have "proven their loyalty" by out-surviving the rest. This is absurd given that, if a company's running well, it should never see anything remotely like the rightward tail of the decline curve. But this is how the corporate ladder game has been run for decades.

A lot of people won't admit this, but they feel the same way about therapy and mood-regulating medications that they do about doping in sports. They're indignant that "the weak" aren't dropping off as quick as they'd like, and that normal people have to compete harder as a result because the people who used to drop off around 30-35 hours per day can now go to the standard 40-50 or more. This is pure speculation, but I've often thought that the emergence of good anti-anxiety drugs and anti-depressants has been a contributing factor to the increasing hours expected in white-collar work (not to say that these drugs are bad-- they aren't, they're lifesaving-- or that people who need them shouldn't use them-- they should) as well as the increasing prevalence of open-plan office layouts where open-back visibility is the norm. Before benzodiazepines, the economics didn't favor open-back visibility. Now, they might. (I still think open-back visibility is a disaster. Not everyone can afford individual offices, but have some decency.)

What makes us unusual in the "hacker" community is that most of us tend to have volatile and steep curves. Under decent conditions where human creativity is at the maximum, we're the top performers. Under pressure-cooker conditions that push people well along the decline curve, we're among the first to fail.

What's changing (in our favor) is economics. Pareto distributions (80-20 laws) can be cruel in terms of the inequality they represent, but those winner-take-all contests (which cause inequality in macroscopic business success, but we never get too tied to a business unless we're founders) are good for us as mercenary programmers. Upper-tier creativity and engineering talent are now worth something. We can sell our skills, finally, for what they're worth.

In the old-style corporate world, work was intellectually easy and tedious, even at executive levels. Coveted positions had to be allocated based on some competition, but the work wasn't deep or genuinely difficult, so the contest became one of doing large amounts of easy commodity work-- 2 to 5 times what a typical person would accomplish in an 8-hour day-- and remaining socially pleasant ("bubbly", even) while doing it. That was how people got ahead. So it was all about the rightward tail of the decline curve, and situational anxiety and depression (again, not severe enough to be life-threatening, but the kind that would make you unemployable for a couple months) were what separated the winners from the losers.

In the new, technological world, the value of commodity work is approaching zero. Upper-level creativity and technological skill, on the other hand, are gold. This means we need to stop the ratrace nonsense and focus on unlocking human potential.

In my personal experience, and I'll keep the details limited, pursuing proper treatment for mental conditions does not reduce creativity for most people. In fact, it's much easier to see creativity through when your brain isn't constantly trolling you. There probably are rare exceptions but, in general, however, altered states without insight (this applies to most drug use and mental illness) are not interesting or creativity-inducing, but unbearably boring and upsetting.

I hope this explains why the cultural issues surrounding anxiety and depression are so hard to address. They're an unspoken but huge player in the corporate ladder game, and there are a lot of people who are afraid that they'll lose ground if more people can seek treatment for these illnesses.

My wife is "neurotic" about other people being behind her and being able to see her computer. She also has significant hang-ups with believing that people don't like her (as far as I can tell, they do), and general depression.

I'd love to get a better idea about whether these are symptoms of a real problem, or just "personality quirks". I've tried to get her to see a doctor about her symptoms of depression and somewhat odd neurosis, but she seems to largely believe the problem external to herself.

Lastly (and I intentionally left this for the end) -- I don't say this lightly, but your position -- that the "normal" people are indignant about having to somehow compete harder due to "the weak" having access to anti-anxiety drugs and anti-depressants -- seems unfounded in the available evidence.

I do think people with mental illnesses are judged harshly, but I don't think it has to do with concern regarding "doping" or some other form of unfair competition.

There are no external problems. Everything is as it is; we choose to interpret the stream of input as problematic, or not. Sometimes we inject falsehoods into the stream ("nobody likes me") to nurse our fear.

It isn't necessary for your wife to live every day peering over her shoulder. Nor convincing herself that her friends and coworkers dislike her. Nor experiencing any of the other anxieties she no doubt simply takes for granted. As someone who carted so many around for not less than a decade, believe me: they're not worth the luggage fees.

Open-back visibility is unnatural. Picture a man, comfortably reading a book, and a tree. Where is the tree? Invariably, it's right behind him.

When people are in a loud or uncomfortable environment, one of the first instincts is to guard their back. Modern office environments don't allow this. Most have traffic corridors behind the person who is working. Over 8 hours, the stress builds up.

My wife is "neurotic" about other people being behind her and being able to see her computer. She also has significant hang-ups with believing that people don't like her (as far as I can tell, they do), and general depression.

I'm not a doctor, and I don't know your wife, but to me, this sounds like social anxiety. A lot of office environments make it 10 times worse than it needs to be.

There's also such a thing as "secondary depression", which is depression induced by an anxiety disorder. Office-induced social anxiety usually leads that way.

At some point, I learned that no one cares what is on my computer (as long as I'm not obviously fucking off) because everyone is playing his or her game rather than trying to evaluate mine, but it took me years to really get that.

your position -- that the "normal" people are indignant about having to somehow compete harder due to "the weak" having access to anti-anxiety drugs and anti-depressants -- seems unfounded in the available evidence.

No, not all the "normal" people. However, there are people out there who feel very negatively about the use of these drugs, that they're "propping up the weak", and this is the source of that attitude. Society has been stack-ranking people for some time based on their ability to handle stupid stresses in large amounts, and psychiatric medicines change the game. But that's a good thing, because that game doesn't deserve to exist in the first place.

See for example mfceo's response on the Depression Lies thread:

http://news.ycombinator.com/item?id=4510255

"Now there is one more pilled up dude out there that i will have to compete with. Although i do try to live my life the healthiest way i can afford and cut all other bs aside, i do find it sometimes difficult to compete agains all these people on meds as they don't have to deal with as much humane feelings anymore but can act out, in the worst case, their over the top happy personalities and don't feel like normal humans do"