But she suffers off-and-on depression. Not just "I feel bad" depression. Crippling, "can't get out of bed" depression. Periodic suicidal ideation. Occasional suicide attempts.

She knows she has depression. She talks about it. And she wants to be done with it. She knows how she feels when her brain is "in balance" and how it feels when she's depressed. One of these states is much more preferable to the other.

She's tried drugs, ECT, talk therapy, etc. And, yes, she's tried ketamine. Anything that will put her back to a state where she is able to get out of bed and function, and reduce the odds of her killing herself when she's depressed.

I'm sure there are a lot of people who are depressed due to outside factors -- poverty, oppression, war, etc. But I can tell you quite certainly that there are people who have "perfect" lives who find themselves clinically depressed. And at least some of those people want to get back to a non-depressed state. This research helps them.

TL;DR: Not all people are depressed because their life sucks, nor is depression something that all people can "cure" by thinking harder or trying harder. Some people have a brain imbalance and would like to fix it so they can have a life. Literally.

I dated for 5 years a woman in the same situation as what you describe. She has money, friends, family, a roof over her head. She hasn't suffered childhood trauma or anything abnormal, but she's consistently depressed and lethargic.

I'm bipolar myself. I've been through some difficult things, but my condition makes me acutely aware of how subjective human emotions are. How much of our thinking is influenced my neurochemistry rather than rational thoughts or memories. I'm pretty stable these days, but I've had times where I would just wake up in the morning and feel happy to be alive. Energized, stress-free, and confident in my abilities. The next day, I wake up depressed and I feel like my life is shit, not worth living. A few days later I feel fine again. No major life events, no major causes of stress, just my neurochemistry being unpredictable.

I think that the overinsistence in some circles on past trauma causing mental illness is harmful. There is definitely such a thing as genetic predispositions. Some depression and mental illness just does not have a cause you can point to. It's not all about overcoming negative experiences and willing yourself out of it. Genetic defects can cause all sorts of physical problems, just think of psoriasis, asthma, acne and peanut allergies. I'm not sure why people think that the brain can't have such issues. Believe me, people with peanut allergies won't overcome that through psychotherapy and confronting their mommy issues.

But all my research and experiences support the notion that both one's experiences and one's emotional reactions to those experiences are crucial. This is why you can have some people living seemingly perfect lives and winding up depressed, and others living through war and oppression and coming out fine.

In your friend's case, the environmental factors could be: (1) pressure from outsiders to "keep up appearances", (2) the negative messages and images that proliferate through the media of war, poverty, murder, terrorism, climate change etc, (3) a world that offers so many options of how to live but little consistent guidance about what is best, (4) living in a society that can still be very difficult for women, due to career challenges, threat of abuse, paternalistic attitudes etc.

These are just hypothetical of course, given that I don't know her.

And for her to be crippled by depression in response to these or other stimuli would be as much to do with a difference in the way she responds to such things vs the "average" person.

But it may not even be unhealthy. Maybe her true calling is to work as a humanitarian helping the needy rather than doing what she's been trying to do, and her depression is her mind's way of making her realise she needs to make that kind of change.

Having gone through this process in myself and with others, when you dig deep enough, something like this always turns out to be there.

But my main point is that the mind does not and cannot function independently of a person's environment, and paths to mental wellness that really work (and they do exist), involve addressing both one's inner reactions to things and one'e outer environment.

Yet I still have episodes where I sometimes can't get out of bed, or can't bring myself to leave the house. A couple of months ago I spent three days just sitting (and occasionally sleeping) in a chair, not even getting up to eat or shower. I just simply couldn't do it.

While it's true that people can experience temporary depressive episodes due to 'exogenous' factors (e.g. the death of a loved one), it is very different to 'endogenous' depression, and requires different types of treatment. While talk therapy and time can be very helpful for people to work through difficult and temporary 'adverse circumstances', it is of little help for endogenous/biological depression.

No amount of 'talk therapy' can convince my pre-frontal cortex to operate within 'normal' parameters or to get my brain to produce appropriate quantities of neurotransmitters like serotonin, dopamine and noradrenaline. I'm reasonably sure this is a chronic illness that I will never be rid of (as I've learned from 15 years of failed treatment attempts). On the upside, there's a good chance that there is some treatment out there, coupled with sustained lifestyle changes, that will allow me to stave off the symptoms so that I can live a relatively 'normal' life. In some ways it's similar to how type 1 diabetics can survive and live normal lives with regular injections of insulin.

- running multiple ultramarathons with too little rest can cause depression, even if you love it. - working very hard in a job you like with too little sleep for a long time can cause depression.

In both cases it's likely your brain it just telling you that you're pushing too hard.

Some people -- like me -- find it easier to get into these mental overdrive situations, and some people might be more likely to suffer depression from the same stressors, but ultimately it seems to be the same factors at work.

I don't want to be preachy...one thing I've come to realize from many online discussions with other people suffering from depression is that almost every case is unique in some way and that the mental health community's efforts to try to group together what we're feeling into a single problem with prescribed courses of treatment is probably counterproductive. People believe that because they've experienced depression, either first- or second-hand, that they understand what all depression is like...astazangasta's comment is an example of this.

I try not to be one of those people, so what I'm offering is a suggestion, not an answer. My depression is by no means fixed, but meditation has helped me. It's one datapoint in case you want to try it.

It's not that I don't believe your depression is endogenous, I'm just curious. I was in a similar position to you until I looked closely at my life and identified the factors that were causing my depression/CFS.

I think that someone can be affected by somethings in their earlier life that can affect them forever. I'm not talk about repressed memories, I'm talking about the lack of positively formative experiences at critical moments of their life.

Example - what happens when say someone starts school or is a teenager at the same time their mother is undergoing menopause and their father has lost their job and they're both starting to drink? The child will feel a lack of something but not sure what. If they do think of it all, they'll think of it as partly their fault.

How can you be sure it's not WiFi radio waves messing with her brain?

Can you really rule out space aliens trying to stop her from reaching her potential?

There's a reason we use the scientific method.

Could it possibly be that there is more to life than these things?

...could it be that there is more to life than these "objective factors"?

Hacker news is pretty depressing.

Sure the propensity to feel depressed in response to a given experience may differ from person to person, but it is a product of evolution, and is far too common to be pathologised as a "disorder".

We have this assumption that a materially privileged life in a rich society should entitle us to a life of happiness, and any divergence from that is an "illness".

This ignores the fact that there is much that is unhealthy about modern western society, and the proliferation of depression among seemingly well-off people in rich societies is a natural reaction to that.

I can tell you that my condition eventually responded dramatically to medication, and that I would not be able to live the life I live now if it were not for that medication; furthermore, that because of the medication and my experience during the years I have been on it, I can look forwards to continuing to reduce my dependence on that medication.

Depression is indeed a normal response to ongoing helplessness and despair. I probably share your experience of depression in this regard, because the 'depression' that I had been treated for for years was suddenly completely irrelevant the moment my brain finally responded to medication.

However, there are several things that this account leaves out. You can't scoff and say that depression is just an normal response any more than people can scoff and say the reason you don't want to take a shower is because you're lazy. For one, as you know, depression can be very self-perpetuating. People come to believe things that keep them depressed, ruminating on their depressed state over and over again. People always see verification and never contradiction of their worldview, even though the entire world has somehow failed to just lay down and die over the course of many thousands of years, which is what it would do if that understanding of reality was valid. And people very definitely do encounter depression that does not have a proximate external cause to justify the response; many of those Afghanis, for instance, will suffer from the bleakest of depressions for many years after the wars in Afghanistan are ended. All of these things constitute a medical condition. If you don't like the word "illness" because of how it makes you feel, I can sympathize. But that doesn't invalidate the fact that depression is something that frequently does become a genuine medical problem and frequently does require a solution beyond the reach of the person suffering from it.

Well, no you can't because it seems a lot of people with really good life are just struck by it.

Although I believe the environment (physical, emotional, relational [edit: in recovery or/and prevention]) plays a huge role there still seems to be something extra going on.

For the first decade or so after being diagnosed with depression I believed it could only be explained by brain chemistry or something like that. Only later in life when I learned more about healthy relationships and what does and doesn't work for me emotionally did I realize that my depression was an obvious reaction to the dysfunctional environment I was raised in.

My ignorance of the non-chemical causes of my depression made me feel I was "just struck by it". But there really was a cause in my environment. I believe this is true for many other people as well.

Depression and anxiety in particular I think are better explained as a mismatch between human adaptation and current human environment. They are signals that things are unsafe/insecure. It seems to me more wise to focus on improving our environment than on constantly blaming the brain, whether through the serotonin hypothesis or this new neuroconnectivity approach.

But I still strongly agree with your point. My strongest influence on this stuff is The Biology of Belief by Bruce Lipton, who explains how it all works on a cellular and genetic level.

It's interesting that the Ketamine research comes to the conclusion that depression is not a mental imbalance but is a product of the environment causing structural changes in the brain - this seems more in line with what eg ADD and Depression ACTUALLY are - it's not that I can't focus because I caught something from my neighbour - I can't focus because I'm berated with stimuli and I can't pick just one thing to focus on. I'm not depressed because my brain isn't producing enough seratonin, it's because I've been wore down supressing my wants and needs and extended myself trying to make other people happy or overstimulated myself or whatever.

We don't know but the picture is getting clearer - depression isn't a common cold that you need drugs for - it's more like liver disease caused from chronic drinking. Stop drinking, and let your liver recover only science just barely understands the processes of the psyche and environment that cause those physical changes in the brain yet.

Addiction itself is very much an obvious facet - it's not a degenrate behavior but a degenerative structural change to the brain that cause inner behavioral and perceptual changes that need a physical restructuring of the brain to overcome.

It will take time but science will get clearer. The problem is that there are many motives - the whole "sitting is the new smoking" awareness is evidence that we focus on the wrong things - why is this just coming out now? because there is no profit motive to fund that research.

Do you doubt the existence of autism? Dyslexia?

Probably not.

Sorry that it can't play the role in your polemic that you were hoping for.

BTW. I always considered ADD, ADHD, etc. to be a bit of a fake disease, a product of environment, but I'm no longer sure. I've been struggling with depression and anxiety for many years and responded relatively well to SSRIs which stabilized my mood and helped me quit the recurring panic attacks. The problem is not gone, but with a little more stable emotional situation I managed to figure out that what really causes most of my problems now is total lack of focus. I can't hold my attention on any kind of work-related task (the task doesn't matter; what matters is that it's work) for more than 30 seconds without compulsively seeking something else to do. Be it HN or IMs. With no easy distraction source available, I'll get anxious and sleepy. I can be perfectly well-rested but will still occasionally get sleepy at work just because I refuse to distract myself with Hacker News. A considerable amount of my mental energy goes to fighting this and forcing myself to focus. Now that I've finally dug that up from underneath the layers of anxiety, it's going to be a topic of the next conversation with my doctor.

#HNTherapy

Also, this is what I got googling for ADD[2]. What the shit?

[0] - http://slatestarcodex.com/2014/09/10/society-is-fixed-biolog...

[1] - http://lesswrong.com/lw/2as/diseased_thinking_dissolving_que...

[2] - http://i.imgur.com/n5nhyWt.png

The main reason for this is that it's fallacious to think that your emotions are "completely independent of your life circumstances". They're symbiotic.

I was born into modest privilege and had an upbringing that was free of abuse or major trauma, and the only things that have gone severely wrong for me in life have been through my own poor decisions.

Yet I can now easily see how the depression I've experienced was due to a combination of living in a somewhat unhealthy environment and having a propensity to respond to that environment by becoming depressed and fatigued. I can now see the same applies to everyone else I know of who experiences depression.

The explanation you've given is embraced by mental health professionals as it allows them to justify attempting to cure it with pharmaceuticals and short therapy consultations, but as the data shows, that approach has a pretty low success rate.

I also agree with your point about "people reacting to things with the wrong emotions or the wrong intensity of emotion"; understanding and addressing this has been fundamental to my own recovery.

What I'm disputing is the notion that there is a clear-cut distinction between "exogenous" and "endogenous" depression, and that one is "totally unrelated" to the other. Nothing in biology - or in and truly complex system - works like that.

That said, I'm not presuming to be able to change your mind, but more pointing out that the premise your position relies on - that one's environment and one's emotional response to their environment are completely independent - is neither an undisputed scientific fact nor true in my own experience or anyone else I've observed.

While I agree that neither exist in complete isolation, it still doesn't preclude one from being the dominant cause.

Moreover, not many people would advance the same argument in regards to conditions such as schizophrenia or bipolar disorder—how clinical depression is somehow special and not deserving of the same [endogenous] understanding is beyond me.

Well the argument I was responding to was that the two are completely unrelated, so if you accept that they're not, we're mostly on the same page.

The question then is how common it is for one to be overwhelmingly dominant.

From my experiences and research, I'd suggest that like most other biological phenomena, it fits a Gaussian distribution, in which for the majority of people it would be within 75/25 in either direction.

Moreover, not many people would advance the same argument in regards to conditions such as schizophrenia or bipolar disorder

This may be where I lose you completely, but I would make the same argument for those conditions.

It's common for the manifestations of those illnesses to be triggered by an acute trauma or prolonged exposure to abuse. But of course the innate propensity to develop that condition had to be there too.

In my own experience, I exhibited bipolar tendencies years ago (as strongly as others I know who were formally diagnosed with it). Since changing both my environment and my emotional tendencies, I no longer do.

Others with schizophrenia report becoming symptom-free by following a similar approach.

I'd contend that the whole reason mainstream medicine continues to be so hit-and-miss when it comes to treating mental "illness" is that it continues to resist viewing it in this way.

While I'm not disputing that emotional techniques can be beneficial, my main point was that in certain cases, the cause of the condition is probably the result of overwhelmingly dominant biochemical or physiological factors.

Meta-analysis has shown that approximately 80% of all cases of depression are initially caused by a major life stress (1). So "exogenous" factors seem to play a large role in triggering most depression. That said, not everyone develops depression following a major life stress - people have different levels of "endogenous" stress resilience/susceptibility. "Endogenous" stress resilience can be modulated, however, by "exogenous" interventions. For example, resilience can be increased by behavioral stress inoculation or even exercise, and it can be decreased by things like sleep deprivation or illness. It can also be partially inherited (i.e., if someone's parents were "exogenously" stressed, the offspring can inherit lower levels of stress resilience through "endogenous" epigenetic changes) (2).

And though 80% of initial depressive episodes may be triggered by stress, this tight correlation between stress and depression does not persist as strongly after the first depressive episode. Essentially, once someone has been depressed a first time, they are then "endogenously" more susceptible to subsequent episodes of depression.

So, is it exogenous or endogenous? Long story short, in most cases, it's both. Even if it doesn't start as both, it becomes both. And both "exogenous" and "endogenous" contributing factors interact in an on-going dynamic process.

1. http://hammenlab.psych.ucla.edu/pubs/05stressand.pdf 2. http://www.ncbi.nlm.nih.gov/pubmed/26410355

My own view is that depression is an evolved response to negative stresses and situations, and that clinical depression is the far end of this scale. Depression is therefore your brain's way of telling you that you need get out of a bad situation. Schizophrenia seems to be akin to a flaw resulting from some evolutionary aspect of the brain's operation, perhaps due to creativity/intelligence.

How do you reconcile this with cases of clinical depression where the person's life is otherwise fantastic, and yet they suffer from crippling depression anyways—absent any negative stresses or situations?

I think the mistake here is to assume that a privileged life is a good life.

All the comments here that say things like "they had plenty of money, good looks, great career etc but were crippled by depression" make that mistake.

If there's biological factors working against a person harder than any emotional/environmental/life changes can correct for, then those techniques are ultimately rendered inadequate.

The biological factors are symbiotic with the environmental factors. One does not function in isolation from the other. If your biology is preventing you from enjoying your supposedly "good" life, you don't really have a good life at all. Depression is one way in which the mind signals that.

The way to have a life that is actually good is to bring your environment and your biology into balance.

Such techniques exist and are highly effective for people who are fortunate enough to be able to discover and adopt them (of whom I'm one).

That they're not widely accepted in the mainstream doesn't diminish from their existence or their effectiveness.

As I've said earlier, I understand your point of view as it's one I held for a long time.

Since I learned the way of thinking about it that I've been arguing here, I've been able to take meaningful action that has allowed me to overcome depression and build a life that is actually good rather than just appearing good (both to outsiders and to my delusional self).

Anyway, I won't be responding further; you've made your point well, I've made mine and I hope my comments have helped you to clarify your own thinking, as yours have mine. Thank you for the discussion, it's an important issue that I appreciate people making the effort to engage in.

Agreed. To note I had originally phrased it as an "otherwise fantastic life" but it kind of turned into a semantics argument.

>The way to have a life that is actually good is to bring your environment and your biology into balance.

My position wasn't that environmental or emotional techniques are ineffective, just that sometimes they're inadequate in face of overwhelming biological factors, necessitating biological intervention as well. But hey—I think we're finally in agreement.

>Since I learned the way of thinking about it that I've been arguing here, I've been able to take meaningful action ...

That's great. Please don't take what I said as an indictment or assault against what works for you, I certainly didn't mean it that way.

>Anyway, I won't be responding further; you've made your point well, I've made mine and I hope my comments have helped you to clarify your own thinking, as yours have mine. Thank you for the discussion, it's an important issue that I appreciate people making the effort to engage in.

Likewise. Have a good one. :)

https://news.ycombinator.com/item?id=10761938

Perhaps they can provide some insight as to how.

I was in similar denial at the beginning, until I realised that these factors are important.

I'm certainly open to the possibility that depression might be possible for someone with a fantastic life, but from what I've seen that doesn't correspond with the experiences of myself and friends/family who have experienced it.

I don't know how you'd differentiate between this formally, but it seems there is a massive difference - and they need different solutions.

[ edit readability ]

My point is that it would help if this distinction permeated into the popular discourse on depression ...

[ Awareness of the distinction might make the general public more likely to question the morality of pumping up soldiers with anti-depressant drugs before they go into battle, for example ]